PMT17-01564 City of Menifee Permit No.: PMT17-01664
29714 HAUN RD.
r'�CCELA? MENIFEE,CA 92586 Type: Residential Plumbing
MENIFEE Date Issued:
05N8/2017
PERMIT
Site Address: 28943 E WORCESTER RD, MENIFEE, CA Parcel Number: 337-131-017
92586 Construction Cost: $979.00
Existing Use: Proposed Use:
Description of REPLACE 40 GAL WATER HEATER IN CLOSET
Work:
Owner Contractor
SAM AHMED AFFORDABLE WATER HEATERS AND PLUMBING
28943 E WORCESTER ROAD INC
MENIFEE,CA 92586 28358 CONSTELLATION ROAD#698
Applicant Phone:8553459087
DANIEL MATA License Number.627368
AFFORDABLE WATER HEATERS AND PLUMBING INC
28358 CONSTELLATION ROAD#698
VALENCIA,CA 91355
Fee Description City Amount ISl
Residential Water Heater 1 83.00
Building Permit Issuance 1 27.00
GREEN FEE 1 1.00
General Plan Maintenance Fee-Plumbing. 1 4.15
$115.16
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 carded 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_Bldg_Permit_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 ❑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 Cla s 11) w4se No. �,, Ays By my signature below I acknowledge that,except formy personal residence
Expires Signatur in which I must have resided for at least one year prior to completion of
improvements covered by this permit.I cannot legally sell a structure that
WORKER'S COMPENSATION DECLARATION have built as an owner-builder if it has not been constructed in its entirety by
o 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 worker's 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
www.leainfo.ca.aav/calasv.html.
this permit is issued.
.Policy# Date
I have and will maintain worker's compensation insurance,as required by
iPROPERTY OWNER OR AUTHORIZED AGENT
section 3700 of the Labor Code,for the performance of the work for which o 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
'� �I' `/1't�� building construction.i authorize representatives of this city or county to
Policy.iNsmos iko oo ExpiresV, L enter the above identified property for inspection purposes.
(This section need not to be completed is the permit is for one-hundred - Date
dollars($100)or less PROPERTY OWNER OR AUTHORIZED AGENT
o I certify that in the performance of the work for which this permit is issued,
1 shall not emolov any persons in any manner so as to become subject to the CITY BUSINESS LICENSE#
workers compensation laws of California,a agree that if I should become HAZARDOUS MATERIAL DECLARATION
subje?sha
wo kers wmpen anon isions of5ection 370Dofthe Lppbor
with come It epronsWill theapplicant or future buildingoccupant handlehazardous material ora
omi#ure containing a hazardous material equal to orgreater that the
amounts specified on the Hazardous Materials Information Guide?
ILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS ❑Yes ONO
UNLAWFUL,AND SHALL SUBIECFAN 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($300,000),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 for guidelines
CONSTRUCTION LENDING AGENCY ❑Yes ONO
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 o No
OWNER BUILDER DECLARATIONS - 1 have read the Hazardous Material Information Guide and the SCAQMD
1 hereby affirm under penalty of perjury that I am exempt from the permitting checklist.I understand my requirements under the State of
California Health&Safety Code,Section 25505 and 25534 concerning
Contractors License Law for the reason(s)indicated below by the 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 IRRPI
License Law(Chapter9(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($50D). _ 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.eav/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 ❑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:
a 1,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 RRP rule please fill out the RRP
Acknowledgement.
SAFETYBUILDING & PERMIT/PLANAPPLICATION
i i." R L•i
�� k
Menifee
DATE � � PERMIT/PLAN CHECK NUMBER
TYPE: O COMMERCIAL RESIDENTIAL O MULTI-FAMILY O MOBILE HOME O POOL/SPA O SIGN
SUBTYPE: O ADDITION O ALTERATION O DEMOLITION O ELECTRICAL O MECHANICAL
ONEW PLUMBINGGq {ORE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORKUM& C`>�Cr
�I Clty of Menlfee
PROJECTADDRESS `r wilding & Safety Dept.
ASSESSOR'S PARCEL NUMBER Z5 - 1 1-1 LOT TRACT
PROPERTY OWNER'S NAME cNAMO
ADDRESS Q Receive
PHONEY 11� ' �lC/ EMAIL
APPLICANT NAME U
ADDRESS
PHONE . EMAIL
CONTRACTOR'S NAME OWNER BUILDER? O YES O NO
BUSINESS NAMEJ%ffootS
ADDRESS ('V� 0%
PHONE ""[EMAIL
CONTRACTOR'S STATE LIC NUMBER ���>(/-p ICENSE CLASSIFICATION
VALUATIONS v\ SQ FT L SO FT
APPLICANT'S SIGNATURE DATE
CITY STAFF USE OIVLY
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN SMIP
INVOICE PAID AMOUNT
AMOUNT O CASH O CHECK# O CREDIT CARD VISA/MC
PLAN CHECK FEES PAIDAMOUNT OCASH OCHECK# OCREDITCARD VISA/MC
OWNER BUILDER VERIFIED OYES O NO DLNUMBER NOTARIZEDLETTER O YES O NO
City of Menifee Building&Safety Department 29714 Noun Rd. Menifee, CA 92586 951-672-6777
www.cityofinenifee.us los,oection Request Line 951-245-62132
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