PMT17-01854 City of Menifee Permit No.: PMT17-01854
29714 HAUN RD.
�A-CCEL/> MENIFEE, CA 92586 Type: Residential Plumbing
MENIFEE Date Issued:
06/12/2017
PERMIT
Site Address: 28735 AUTUMN LN, MENIFEE, CA 92584 Parcel Number: 372-420-005
Construction Cost: $4,576.00
Existing Use: Proposed Use:
Description of REPLACE BACKWATER DEVICE IN GARAGE
Work:
Owner Contractor
ROGER COPP A R S AMERICAN RESIDENTIAL SERVICES OF
28735 AUTUMN LN CALIFORNIA INC
MENIFEE,CA 92584 965 RIDGE LAKE BLVD SUITE 201
Applicant Phone:9012719700
ANDREW ALLEN License Number:765155
A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIr
965 RIDGE LAKE BLVD SUITE 201
MEMPHIS,CA 38120
Fee Description Qtv Amount(S)
Plumbing Fixtures and Vents,fixtures 1 116.00
Building Permit Issuance 1 27.00
GREEN FEE 1 1.00
General Plan Maintenance Fee-Plumbing 1 5.80
$149.80
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 bulliding 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_81dg_Permit Template.rpt Page 1 of 1
CITY OF MENIFEE
LICENSED DECLARATION property who builds or improves thereon,and who contracts for the projects
hereby affunn under penalty of perjury that 1 am under provisions of with a licensed contractor(s)pursuant to the Contractors State license Law).
Chapter9(commencing with section 700D)of Division 3 of the Business and o I am exempt from Iicensure under the Contractors State License Law for
Professions Code and my license is in full force and effect the following reason:
License CI qq License No By my signature below I acknowledge that,except for my personal residence
Expires N Signature in which I must have resided for at least one year prior to completion of
WORKER'S COMPENSATION DECLARATION improvements covered by this permit.I cannot legally sell a structure that I
have built as an owner-builder if it has not been constructed in its entirety by
D 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 websile:
by Section 3700 of the Labor Code,for the performance of work for which ,„A„A,-leeinfo.ca.eov/oiaw.html.
this permit is issued.
Policy It Date
ave and will maintain workers compensation insurance,as required by PROPERTY OWNER OR AUTHORIZED AGENT
ection 3700 of the Labor Code,for the performance of the work for which D my signature below I certify to each of the following:I am the property
this permit Is issued.My workers compensation insurance carrier and polity wrier or authorized to act on the property owner's behalf.I have read this
number are application and the information I have provided is correct.I agree to comply
,r with all appicmble city and court nances and state laws relating to
Cartier building cci stru I au!Werepresentativu of this city or county to
PoliryN a y, Expires enterth dentifi erty for inspection purposes.
(This section need not to be completed is the permit Is i1r,
one-hundred ^ �(,
Date
dollars($100)or less
PROPERTY OWNER OR AUTHORIZED AGENT
�ertify that in the performance of the work for which this permit is issued,
'I shall not emolov any perso fn any manner so to become subject to the CITY BUSINESS LICENSE g
workers compensation sofC 1" nia,a ree thatif lshouid become HAZARDOUS MATERIAL DECLARATION
subject to the work s com,�PP�ion ' tuns af5ection 3700 ofth Labor
Code,I shall fo ith (/n/pI wit o rov ions. / Will the applicant or future building occupant handle hazardous material ora
Applicant Date S �.f mixture containing a hazardous material equal to or greater that the
amounts spe fled on the Hazardous Materials Information Guide?
WARNING:FAILURE TO SECURE WORKER'S COMPENSATIO COVERAGE IS D Yes No
UNLAWFUL,AND SHALLSUBIECTAN 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($100,000),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(SCAQM D)?See permitting checklist
IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES forguldel�ines
CONSTRUCTION LENDING AGENCY 0 Yes -ONO
N0
I hereby affirm that under the penalty of perjury there is a construction Will the proposed building or modified facility be within 100D 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) D Yes IIANo
OWNER BUILDER DECLARATIONS I have read the Hazardou aterial Information Guide and the S(AQMD
I hereby affirm under penalty of perjurythat 1 am exempt from the permitting checklist. side a my require under the State of
Contractors License Law for the reason(s)indicated below by the California Healt Safe de,Section and 25534 concerning
checkmark(s)I have placed next to the applicable item(s)(Section 7031.5 h/azardous eria rung.
Business and Professions Code).Any city or county that requires a permit to A*es
Date
construct,alter,improve,demolish or repair any structure,prior to its L l
ROPERTY 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 IRRP)
License Law(Chapter 9(commencing with Section 7000)of Division 3 of the The EPA Renovation,Repair and Painting(RAP)Rule requires contractors
Business and Professions Code)or that he or she is exempt from Iicensure 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
D 1,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.zov/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 uAn 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 RRP rule please fill out the RRP
Acknowledgement.
BUILDING • APPLICATION
Jj yg3, .
I _
,Menifee
DATE (o - C1 11 PERMIT/PLAN CHECK NUMBER (� -101 D
TYPE: [-]COMMERCIAL ❑RESIDENTIAL [-]MULTI-FAMILY ❑MOBILEHOME ❑POOL/SPA ❑SIGN
SUBTYPE: [-]ADDITION ❑ALTERATION ❑DEMOLITION ❑ELECTRICAL ❑MECHANICAL
❑NEW QPLUMBING ❑RE-ROOF-NUMBEROFSQUARES
DESCRIPTION OF WORK 2G c. a a'Q✓ 1/� a r
PROJECTADDRESS OLQ1 otut&y\ Y\ 5
ASSESSOR'S PARCEL NUMBER 3'Ip1 .�(-�o`�OS LOT TRACT
OWNER NAME fzC e ( CO
ADDRESS 5 q t 6L
PHONE 6 Wz) EMAIL
APPLICANT NAME �,w . L�6&n
ADDRESS J0.Nat G J
PHONE 17sk EMAIL
CONTRACTOR'S NAME OWNER BUILDER? ❑YESE NNO
BUSINESS NAME QQ
ADDRESS SeZO —) L-k�aBN C a
PHONE 93111 -y EMAIL
CONTRACTOR'S STATE LIC NUMBER / (P,5-i LICENSE CLASSIFICATION C Co
VALUATION$ L-{ to-7 Le S L SQ FT
APPLICANT'S SIGNATURE DATE Co -/L - /
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN SMIP
INVOICE PAIDAMOUNT
AMOUNT OCASH OCHECK# 0CREDIT CARD VISA/MC
PLAN CHECK FEES PAIDAMOUM OCASH OCHECKk OCREDIT CARD VISA/MC
OWNER BUILDER VERIFIED OYES O NO DLNUMBER NOTARIZEDLE17ER O YES O NO
City of Menifee Building&Safety Department 29714 Haun Rd. Menifee, CA 92586 951-672-6777
www.cityofinenifee.us Inspection Request Line 951-246-5213