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PMT17-01904 City of Menifee Permit No-: PMT17-01904 29714 HAUN RD. T Residential Electrical '�CCELA_. MENIFEE,CA 92586 yam' am,.,.-,tsMtr MENIFEE Date Issued: 06/1 a/2017 PERMIT Site Address: 26230 BURLINGTON WAY, MENIFEE, CA Parcel Number: 337-112-020 92586 Construction Cost: $1,000.00 Existing Use: Proposed Use: Description of PANEL UPGRADE 100 AMPS MAIN TO 200 AMPS Work: Owner Contractor MARK BLEEKER MYERS ELECTRIC CO 26230 BURLINGTON 425 W LA CADENA DR#21 MENIFEE,CA 92586 RIVERSIDE,CA 92501 Applicant Phone:9516628769 DOMINIQUE ANNETT License Number:972274 MYERS ELECTRIC CO 425 W LA CADENA DR#21 RIVERSIDE, CA 92501 Fee Description ON Amount lSl Services, Switchboards, Control Centers&Panels 1 116.00 Building Permit Issuance 1 27.00 GREEN FEE 1 1.00 General Plan Maintenance Fee-Electrical 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 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_Bldg_Pemit Template.rpt Page 1 of 1 CITY OF MENIFEE LICENSED DECLARATION property who builds or improves thereon,and who contracts for the projects 1 hereby affirm under penalty of perjury that I am under provisions of with a licensed contractors)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 t^my license is in full force and effect. / the following reason: License Class VW /d License No. `571 Z�`? By my signature below I acknowledge that,except for my personal residence Expires Lf 30 [6 Signature e7i vr- ct 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 pi 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/calaw.html. ff�1 Policy# 91SS� �i ZJ17 Date nim have and will maintain workers compensation insurance,as required by PROPERTY OWNER OR 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 c Carrier .] at�L, FV J with all applicable city and county ordinances and state laws relating to q building construction.I authorize representatives of this city or county,to Policy# Expires 2 l\_)L41 I iii 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 p,l 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 fort th comply with those p visions. Will the applicant or future building occupant handle hazardous material or a Applicant �r�� r .aP/pate mixture containing hazardous material equal to or greater that the ' amounts specified on the Hazardous Materials Information Guide? WARNING:FAILURE TO SECURE WORKER'S COMPENSATION C VE GE IS ❑Yes ''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($100,(100),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 forguidell��'ines CONSTRUCNON LENDING AGENCY ❑Yes -bNo I 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) ❑Yes ,Q 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 California Health al Safety Code,Section 25505 and 25534 concerning Contractors License Law for the reason(s)indicated below by the concerning checkmark(s)I have placed next to the applicable items)(Section 7031.5 hazardous material reporting. Business and Professions Code).Any city or county that requires a permit to No ,// construct,alter,improve,demolish or repair any structure,prior to its rrYYtarvu�av"c ""`e6�Date /7 414 issuance,also requires the applicant for the permit to file a signed statement PROPERTY OWNER OR AYJTHOR17ED AGENT 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 that receiving compensation for most work t disturbs paint in apre-1978 and the basis for the alleged exemption.Any violation of Section 7031.5 by residence or childcare facility to be work thartified firms and comply with than Applicant for a permit subjects the applicant to o 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 I,as owner of the property,or my employee with wages as their sale 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.gov/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 D property who,through employees'or personal effort,builds or improves the An EPA Lead-Safe Certified Renovator will be responsible for this project 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. ❑No EPA Lead-Safe Certified Firm is required for this project because: ❑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. BUILDING : APPLICATION Menifee DATE E PERMIT/PLAN CHECK NUMBERJUT n- 1,ia TYPE: [:]COMMERCIAL RESIDENTIAL ❑MULTI-FAMILY ❑MOBILE HOME ❑POOL/SPA ❑SIGN SUBTYPE: ❑ADDITION []ALTERATION ❑DEMOLITION ®ELECTRICAL [-]MECHANICAL [-]NEW ❑PLUMBING ❑RE-ROOF-NUMBER OF SQUARES DESCRIPTION OF WORK ivE vpai YtiJ"L b0 00 PROJECT ADDRESS 2lP Z IJ r j 1l1 . o ASSESSOR'S PARCEL NUMBER LOT 3 2. TRACT 'Z - PROPERTY OWNER'S NAME Mr�aL1 - ? ADDRESS 'ebb O(i+v SvN 6rV PHONE EMAIL APPLICANT NAME ffl VQ A 5 YerTkl C o .nw ADDRESS 14257 w Z.4 •,� i^ v"crSlo� d/ PHONE EMAIL CONTRACTOR'S NAME OWNER BUILDER? ❑YES❑NO BUSINESS NAME m y /1 ' f t icTriC 6�66 ADDRESS G/Q W tit Cad !r /' ejvfr=S+�'r / PHONE EMAIL CONTRACTOR'S STATE LICN f'I-7 UMBER 22 7 `1 LICENSE CLASSIFICATION 1JIb VALUATION$ / we SQ FT L SQ FT APPLICANT'S SIGNATURE o' DATE //I/ G DEPARTMENT DISTRIBUTION W CITY OF MEQ `NIFEr Q E BUSINESS LICENSE NUMBER BUILDING NNING ENGINEERING FIRE GREEN I• SMIP „Vl` I 4' 1 INVOIC 14q•aD PAID AMOUNT AMOUNT 1 OCASH OCHELKp OCREDIT CARD VISA/MC PLAN CHECK FEES PAIDAMOUNT OCASH OCHECK# OCREDITCARD VISA/MC OWNER BUILDER VERIFIED OYES O NO DL NUMBER NOTARIZED LETTER O YES O NO City of Menifee Building &Safety Department 29714 H�do hy/W.Wfto. CA 92586 951-672-6777 www.cityofinenifee.uslnspection yag &iSa9S1-26-6213 JUN 14 29V Received Myers Electric Co. 425 W La Cadena #21 Riverside, CA 92501 License# 972274 November 30, 2016 — November 30, 2017 To Whom It May Concern: Myers Electric Company, hereby authorizes the following employees to submit and receive permits on our company's behalf: Andrew Stauffacher Josh Nall Jim Mumme Joshua Clabough Eric Reading Richard Gutierrez Desiree Rash Justin Monjarez Carlos Guerra Ryan Whittemore Christian Monjaraz Samuel Bruno Christopher Senn Clifton Thomas Daniel Martinez Christian Thomas David Gutierrez Mike Good David Gerhardt Martin Huerta Indio Marquez Jacob Pennington John P Henry Chaz Ulloa Jose Alvarez Ramos Benjamin Alejandre Joshua Hemsley Paul Cortez Ashley Atwater Dominique Annett Deborah Dubois Ryan Lewis Cordially, r ep\2Lo�z� ies t. M st My rs, O er D,ty I Satety DeP M rs Electric C . (951) 662-8769 g��dtn9 '�N 1 y 2011 i CALIFOF "iA ALL-FURPosg ACKNDWLEDGMENT CIVIL CODE§1189 a A notary ublic or ether ofncer completing this certificate verifies only the Identity of the Individual who signed the documen to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document. State of C Itfomia I County of Riverside On 11-3 -16 before me, Cindy Hutton, Notary Public Date Here Insert Name and rtle of the Officer personally appeared Forrest Myers Name(s)of Signers) who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/aae subscribed to the within instrument and acknowledged to me that he/his/I ear Wq*authorized capacity(tas�,and that by his/W/ slgnature(�own the Instrumentexecuted the same in he person(, or the entity upon behalf of which the person(aJ acted,executed the instrument. i I certify under PENALTY OF PERJURY under the laws if of the State of California that the foregoing paragraph is true and correct. CINDY HUTTON WITNESS my hand and official seal. COMM.#20S551€ m rn ' NotaryP RNRSIDEE coUPTyy Signature ( t Nr C " .NOV.7,111a Signature bf Notary Public Place Notary Seat Above OPTIONAL Though this section is optional, completing this information can deter alteration of the document or i fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: Document date: Signer(s) Other Than Named Above: Number of Pages; Capacity(ies) Claimed by Signer(s) Signer's Name: Signer's Name: ❑Corporate Officer—Titles). ❑Corporate Officer—Title(s); ❑Partner - ❑Llmited ❑General r Partner— ❑Limited ❑General ❑Individual: ❑Attorney in Fact ❑Individual ❑Trustee ❑Guardian or Conservator ❑Attomey in Fact ❑Other: ❑Trustee ❑Guardian or Conservator Signer Is Representing: ❑ Other: Signer Is Representing: ,r 02015 National Notary Association•www.NationalNot Q q o �N i 9, � 00 US NOTARY(1-800 876-G827) Item 45007 a� 5 ge� 1� fed 'Ge