PMT17-01177 City of Menifee Permit No.: PMT17-01177
29714 HAUN RD. T Commercial Alteration
�ACCEU/ MENIFEE, CA 92586 Type:
MENIFEE Date Issued:
OBID7/2D17
PERMIT
Site Address: 28237 LA PIEDRA RD, MENIFEE, CA Parcel Number: 364-070-031
92584 Construction Cost: $4,000.00
Existing Use: Proposed Use:
Description of TEMPORARY EVENT FOR GOSCH AUTO GROUP AT MSJC.40 X 60 TENT AND GENERATOR
Work:
Owner Contractor
JENNIFER MARRS
28237 LA PIEDRA ROAD
MENIFEE,CA 92584
Applicant License Number:
MENIFEE,CA
Phone:9516583181
Fee Description f3,ttv Amount($1
Power Apparatus 1 150.00
Building Permit Issuance 1 27.00
Additional Plan Review Building 148 148.37
$325.37
The issuance of this permit shall not prevent the building official from thereafter requiring the correction of errors in the plans and
specifications or from preventing builiding operations being carried on thereunder when in violation of the Building Code or of any other
ordinance of City of Menifee.Except as otherwise stated,a permit for construction under which no work is commenced within six
months after issuance,or where the work commenced is suspended or abandoned for six months,shall expire,and fees paid shall be
forfeited.
AA_Bidg_Pennit_Template.rpt Page 1 of 1
CITY OF MENIFEE
LICENSED DECLARATION property who builds or improves thereon,and who contracts for the projects
I hereby affirm under penalty of perjury that I am under provisions of with a licensed contractor(s)pursuant to the Contractors State License Law).
Chapter9(commencing with section 7000)of Division 3 of the Business and o I am exempt from licensure under the Contractor's State License Law for
Professions Code and my license is in full force and effect the following reason:
License Class License No. By my signature below I acknowledge that,except for my personal residence
Expires Signature in which 1 must have resided for at least one year prior to completion of
improvements covered by this permit.I cannot legally sell a structure that I
WORKER'S COMPENSATION DECLARATION have built as an owner-builder if it has not been constructed in its entirety by
❑I hereby affirm under penalty of perjury one of the following declarations:I licensed contractors.I understand that a copy of the applicable law,Section
have and will maintain a certificate of consent of self-insure for workers 7044 of the Business and Professions Code,is available upon request when
compensation,Issued by the Director of Industrial Relations as provided for this application is submitted or at the following website:
by Section 3700 of the Labor Code,for the performance of work for which this permit is issued. www.leeinfo.ca.eov/celaw.html.
^ —
Policy# 11 7t Date 61 -711Z_
I have and will maintain workers compensation insurance,as required by PROPE OWNER R AUTHORIZED AGENT
section 3700 of the Labor Code,for the performance of the work for which ❑By my signature below I certify to each of the following:I am the property
this permit is issued.My workers compensation insurance carrier and policy owner or authorized to act on the property owners behalf.I have read this
number are: application and the information I have provided is correct.I agree to comply
Carrier with all applicable city and county ordinances and state laws relating to
building construction.I authorize representatives of this city or county to
Policy# Expires enter the above identified property for inspection purposes.
(This section need not to be completed is the permit is for one-hundred 1 n � Date v 1
dollars($300)or less PROPERTY OWNER OR AU&6RlZED AGENT
o I certify that in the performance of the work for which this permit is issued,
I shall not emolov any persons in any manner so as to become subject to the CITY BUSINESS LICENSE#
workers compensation laws of California,and agree that if I should become HAZARDOUS MATERIAL DECLARATION
subject to the workers compensation provisions of Section 3700 of the Labor
Code,I shall forthwith comply with those provisions. WIII the applicant or future building occupant handle hazardous material or a
Applicant Date mixture containing a hazardous material equal to or greater that the
amounts specified on the Hazardous Materials Information Guide?
WARNING:FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS ❑Yes o No
UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES Will the Intended use of the building by the applicant or future building
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS($10D,000),IN occupant require a permit for the construction or modification from South
ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR Coast Air Quality Management District(SCAQMD)?See permitting checklist
IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES forguidelines
CONSTRUCTION LENDING AGENCY o Yes o No
1 hereby affirm that under the penalty of perjury there is a construction Will the proposed building or modified facility be within 1000 feet of the
lending agency for the performance of the work which this permit is issued outer boundary of a school?
(Section 3097 Civil Code) o Yes ❑No
OWNER BUILDER DECLARATIONS I have read the Hazardous Material Information Guide and the SCAQMD
I hereby affirm under penalty of perjury that I am exempt from the permitting checklist I understand my requirements under the State of
Contractors License Law far the reason(s)indicated below by the California Health al Safety Code,Section 25505 and 25534 concerning
hazardous material reporting.
checkmark(s)I have placed next to the applicable item(s)(Section 7031.5
oyes o No
Business and Professions Code).Any city or county that requires a permit to Date
construct,alter,improve,demolish or repair any structure,prior to its PROPERTY OWNER OR AUTHORIZED AGENT
issuance,also requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the Contractors State EPA RENOVATION,REPAIR AND PAINTING(RRP)
License Law(Chapter 9(commencing with Section 7000)of Division 3 of the The EPA Renovation,Repair and Painting(RRP)Rule requires contractors
Business and Professions Code)or that he or she is exempt from licensure receiving compensation for most work that disturbs paint in a pre-1978
and the basis for the alleged exemption.Any violation of Section 7031.5 by residence or childcare facility to be RRP-certified firms and comply with
an Applicant for a permit subjects the applicant to a civil penalty of not more required practices.This includes rental property owners and property
than($500). managers who do the paint-disturbing work themselves or through their
o I,as owner of the property,or my employee with wages as their sole employees.For more information about EPA's Renovation Program visit:
compensation,will do( )all of or( )portion of the work,and the structure is www.eoa.eov/lead or contact the National Lead Information Center at
not intended or offered for sale.(Section 7044,Business and Professions 1-800-424-LEAD(5323).
Code;The Contractors State License Law does not apply to an owner of a o An EPA Lead-Safe Certified Renovator will be responsible for this project
property who,through employees'or personal effort,builds or improves the
property provided that the improvements are not intended or offered for Certified Firm Name:
sale.If,however,the building or improvement is sold within one year of Firm Certification No:
completion,the Owner-Builder will have the burden of proving that it was
not built or improved for the purpose of sale. o No EPA Lead-Safe Certified Firm is required for this project because:
o I,as owner of the property am exclusively contracting with licensed
contractors to construct the project(Section 7044,Business and Professions
Code:The Contractors State License Law does not apply to an owner of a If your project does not comply with EPA RAP rule please fill out the RRP
Acknowledgement
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DATE PERMIT/PLAN CHECK NUMBERPM s
TYPE: a COMMERCIAL O RESIDENTIAL O MULTI-FAMILY O MOBILE HOME 0 POOL/SPA 0 SIGN
SUBTYPE: O ADDITION O ALTERATION O DEMOLITION O ELECTRICAL O MECHANICAL
O NEW O PLUMBING O RE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK T
PROJECTADDRESS 207Z3-4 1- ? eckra� wi e CA 6
ASSESSOR'S PARCEL NUMBER 3(e4 rV- 01 -0sl LOT TRACT
OWNER NAME 4P- \
ADDRESS 2 -1 (A-"T
PHONE EMAIL
APPLICANT NAME L !'J C. 7-0
ADDRESS t eo LZ Aq;?9-exr
PHONE )- /n&-Q�. - ) tb 1 EMAIL -II-\-e,SQYD C�) 0,9 k(Y)ajj .0
CONTRACTOR'S NAME OWNER BUILDER? O YES (A NO
BUSINESS NAME
ADDRESS�] LM A N�a'IF: L
PHONE �/ Ll - 9�.—n 1 �'Q'[7 EMAIL 5\VYIVrN a \ n UD
CONTRACTOR'S STATE LIC NUMBER N)p, LICENSE CLASSIFICATION (k
VALUATION$ RY SO FT L SO FT
APPLICANT'S SIGNATURE DATE
DEPARTMENT DISTRIBUTION CRYOE-O"IFEE BUSINESS UCENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN SMIP
INVOICE PAIDAMOUNT O O
AMOUNT O CASH CHECKq CREDIT CARD VISA/MC
PLAN CHECK FEES PAIDAMOUNT I I OCASH 0CHECK# %CREDIT CARD VISA/MC
OWNER BUILDER VERIFIED O YES O NO DL NUMBER NOTARIZED LETTER O YES O NO
City of Menif e Building&Safety Department 29714 Houn Rd. IVlenifee, CA 92586 951-67 W/& Menifee
www.city0finenifee.us inspection Request Line 951-246-6213 Building & Safety Dept.
APR 19 2017
'Okiff
iceopY
MENIFEE BUILDING PERMIT — PROPERTY OWNER'S PACKAGE
Disclosures and forms for Owner-Builders Applying for Construction Permits
IMPORTANTI NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has been submitted in ms your listing yo elf s the builder of
the property improvements.specified at:a &(
are providing you with an Owner-Builder Acknowledgement and Information Verification Form to
make you aware of your responsibilities and possible risk you may incur by having this permit issued
in your name as the Owner-Builder. We will not issue a building permit until y ou have re ad,
initialed your understanding of each pr ovision, si gned, and returned this form to us at our
official address indicated. An agent of the owner cannot execute this notice unless you, the
property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGEMENT AND VERIFICATION OF INFORMATION
DIRECTIONS: Read and initial each statement below to signify that you understand or verify this
information.
1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Builder" building permit that erroneously implies that the property owner is providing his or her own labor and
material personally. I, as the Owner-Builder, may be held liable and subject to serious financial risk for any
injuries sustained by an unlicensed person and his or her employees while working on my property. My
homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder
and am aware of the limits of my insurance coverage for injuries to workers on my property.
2. 1 understand building permits are not required to be signed by property owners unless they are responsible
for the construction and are not hiring a licensed Contractor to assume this responsibility.
3. 1 understand as an"Owner-Builder I am the responsible party of record on the permit. I understand that I
may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his
or her name instead of my own.
�?-�, — 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
,qr numbers on permits and contacts.
5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and
Aztp the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may
be considered an"employer' under Stale and Federal law.
6. 1 understand if I am considered an "employer" under State and Federal law, I must register with the Slate
and Federal government, withhold payroll taxes, provide workers' compensation disability insurance, and
contribute to unemployment compensation for each 'employee." I also understand my failure to abide by
these laws may subject me to serious financial risk.
7. 1 understand under California Contactors' State License Law, an Owner-Builder who builds single-family
- residential structures cannot legally build them with the intent to offer them for sale, unless all work is
performed by licensed subcontractors and the number of structures does not exceed four within any calendar
year, or all of the work is performed under contact with a licensed general building Contractor.
8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable
for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent
construction defects in the workmanship or materials.
8. 1 understand I may obtain more information regarding my obligations as an 'employer' from the Internal
Revenue Service, the United States Small Business Administration, the California Department of Benefit
Payments, and the California Division of Industrial Accidents. I also understand I may contact the California
Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.csib.ca.gov for more information
about licensed contractors.
10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand
that I am the parjy legally�nd fi n�call� res onsible�4r propos d cps Ilion (activity at the following
address: � o�'a; I ( � Cro�naaad4XY9 �.ki0 ( I ��C I
11, 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will
abide by all ap ILicable laws and Muirements that govern Owner-Builders as well as employgly-..
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changers to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the
public. If you contract with someone who does not have a license, the Contractors' State License Board may
be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy
against unlicensed Contractors may be in civil court. It is also important or you to understand that if an
unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may
be held liable or damages. If you obtain a permit as Owner-Builder and wish to hire Contractors, you will be
responsible for verifying whether or not those Contractors are properly licensed and the status of their
workers'compensation insurance coverage.
Before a building permit can be issued, this form must be completed and signed by the
property owner and returned to the agency responsible for issuing the permit. Note: A copy
of the property owner's driver's license, form notarization, or other verification acceptable to
the agency is required to be presented when the permit is issued to verify the property
owner's signature.
Signature of Property Owner:�f�L Date:4 I
Brian Orlauski,Vice President of Business Services
Note: The following Authorization Form is required to be completed by the property owner only when
designating an agent of the property owner to apply for a construction permit for the Owner-Builder.
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal
responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and
file the documents necessary to obtain an Owner-Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No:
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I
personally filled out the above information and certify its accuracy. Note: A copy of the owner's
driver's license, form notarization, or other verification acceptable to the agency is required to be
presented when the permit is issued to verify the property owner's signature.
Signature of Property Owner: Date:
GrTV off,
ENIFE
maw
N
CORRECTIONS
1 st Review
NAME: GOSCH AUTO
PLAN CHECK No: PMT17-01177
ADDRESS: 28237 La Piedra
DESCRIPTION: Used Car Sale w/400sf Tent
DATE: 511/2017
1. Provide a Site plan, Indicate ALL equipment that shall be provided.
2. Include generator, BBQ Trailer, restrooms,Tent seating layout.
Craig Carlson
Building and Safety Manager
City of Menifee
951-723-3729