PMT17-01911 City of Menifee Permit No.: PMT17-01911
29714 HAUN RD. Type: Residential Electrical
'9-�CCIELA�' MENIFEE,CA92586
MENIFEE Date Issued: 08/03/2017
PERMIT
Site Address: 27546 LACOSSE ST, MENIFEE, CA Parcel Number: 360592-010
92584 Construction Cost: $19,024.00
Existing Use: Proposed Use:
Description of INSTALL ROOF MOUNTED SOLAR SYSTEM, 16 PANELS, 1 INVERTER,4.640 kW
Work:
Owner Contractor
KEVIN NICKERSON SOUTHAM AND ASSOCIATES INC
27546 LACOSSE STREET 572 EAST 1700 SOUTH
MENIFEE, CA 92584 AMERICAN FORK, UT 84003
Applicant Phone: 8017961600
RHETT WILLARD License Number.816427
SOUTHAM AND ASSOCIATES INC
572 EAST 1700 SOUTH
AMERICAN FORK, CA 84003
Fee Description 011 Amount($1
Solar, Residential or Small Commercial 1 252.00
Building Permit Issuance 1 27.00
Additional Plan Review Electrical 106 105.60
Additional Plan Review Electrical 4 4.40
GREEN FEE 1 1.00
SMIP RESIDENTIAL 1 3.00
General Plan Maintenance Fee-Electrical 1 12.60
$405.60
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_Permit 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 contractor(s)pursuant to the Contractors State License Law).
Chapter9(commencing with section 7000)of Division 3 of the Business and ❑1 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 C I Q License No, By my signature below I acknowledge that,except for my personal residence
Expires f,�(—�1— ! � Signature in which l must have resided for at least one year prior to completion of
improvements covered by this permit.I cannot legallysell 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 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 vvvvvy,leginfo.ra.gov/calaw.h[ml.
this permit is issued.
Policy# Date
❑I 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
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# U69 L, ? Q Expires 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
❑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 1 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. Will the applicant or future building occupant handle hazardous material or a
Applicant GI Date Y "3'- J� mixture containing a hazardous material equal to or greater that the
amounts specified on the Hazardous Materials Information Guide.
WARNING:FAILURE TO SECURE U ORKER'S COMPENSATION COVERAGE IS ❑Yes oNo
UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES WIII 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(SCAQMD)?See permitting checklist
IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES for guidel�es
CONSTRUCTION LENDING AGENCY ❑Yes /D No
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 P 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 for the reason(s)Indicated below by the California Health al Safety Code,Section 25505 and 25534 concerning
hazardous material reporting.
theckmark(s)I have placed next to the applicable item(s)(Section 7031.5 ayes ❑No p
Business and Professions Code).Any city or county that requires a permit to - Date O
construct,alter,Improve,demolish or repair any structure,priorto its PROPERTY OWNER OR AU ORIZED GENT
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
❑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.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 ❑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. ❑No EPA Lead-Safe Certified Firm is required for this project because:
❑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.
SAFETYBUILDING & • APPLICATION..- Menifee
DATE DATE 0 6/1 212 01 7 PERMIT/PLAN CHECK NUMBER c:� `
TYPE: ❑COMMERCIAL ❑✓ RESIDENTIAL MULTI-FAMILY ❑MOBILE HOME ❑POOL/SPA []SIGN
SUBTYPE: ❑ADDITION ❑ALTERATION ❑DEMOLITION [Z]ELECTRICAL ❑MECHANICAL
❑NEW ❑PLUMBING ❑RE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK Roof mounted PV Solar ; v
PROJECTADDRESS 27546 Lacosse street -A
ASSESSOR'S PARCEL NUMBER 360-592-010 LOT 101 TRACT 31724
PROPERTY OWNER'S NAME Kevin Nickerson CIty of Menifee
ep .
ADDRESS 27546 Lacosse street
PHONE (951)246-7239 EMAIL knickersonl027@yahoo.com
APPLICANT NAME Sarah Hard
ADDRESS 478 S Geneva Rd Orem UT 84058
PHONE (801)854-7042 EMAIL permitting@southamandassociates.com
CONTRACTOR'S NAME southam and associates Inc OWNER BUILDER? ❑YES❑✓ NO
BUSINESS NAME southern and associates inc
ADDRESS 478 S Geneva Rd Orem UT 84058
PHONE (801)854-7042 EMAIL pemitting@southamandassociates.com
CONTRACTOR'S STATE LIC NUMBER 816427 LICENSE CLASSIFICATION C10
VALUATION$ $ 19-024.00 SQ FT L SO FT
APPLICANT'S SIGNATURE .Sa4a.6 DATE 06/12/2017
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN 1 ' SMIP 15 - 1
INVOICE PAID AMOUNT
AMOUNT 1 0CASH O.CHECK# OCREDITCARD VISA/MC
PLAN CHECK FEES PAIDAMOUNT 0CASH 0CHECK# 0 CREDIT CARD VISA/MC
OWNER BUILDER VERIFIED 0 YES O NO DL NUMBER NOTARIZED LETTER O YES 0 NO
City of Menifee Building&Safety Department 29714 Houn Rd. Menifee, CA 92586 951-672-6777
www.cityofinenifee.us Inspection Request Line 951-246-6213
Southam & Associates, Inc.
801796 1600 1 572 E 1700 S. American Fork, LIT 84003
To whom it may concern:
I, Scott Christensen, want it on record that I am authorizing isaak Curry to sign designs/
construction plans, submit and obtain building permits and business licenses for the installation of
photo-voltaic solar arrays in state of California on behalf of my construction company, Southam &
Associates, Inc.
I will be responsible for all work completed under my name. Should you have any questions please
contact me by phone.
801-597-3568 EL2 M 114258
Telephone Number Type of License SCSL Contractor License 8
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Day of vhr, ca —7
Contractor/qualifier Signature i
Sworn before me this day of
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Notary Republic I LYNNM93
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` Istow Of
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My Commission Expires
City of Menifee
Building & WOW Dept.
AUG 0 3 2017
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Bureau Veritas City of Menifee
1665 Scenic Avenue,Suite 200 29714 Haun Rd.
Costa Mesa, CA 92626 Menifee, CA.92586
BV Project: 40017-039331.00 Project: PMT 17-01911
Reviewer: Khoa Duong, P.E Description: Roof Mounted PV System
Direct: 714 4314123
General: 714 4314100
Khoa.duong@us.bureauveritas.com Project Address: 27546 Lacosse Street
Owner(s): Kevin Nickerson
Occupancy Group(s): R-3/U
Construction Type: V-B
PC1-APPROVED
June 26,2017
This plan has been reviewed and approved for conformance to the minimum requirements of the 2016
California Building Standards Code,as amended and adopted by the City of Menifee,California.
1665 Scenic Avenue ♦ Suite 200 ♦Costa Mesa,CA 92626
Phone: (714)431-4100 ♦ Fax: (714)825-0685 ♦ www.us.bureauveritas.com
An Equal Opportunity Employer
Page 1 of 1
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CITY OF MENIFEE
TRANSMITTAL
Building Division
Date: 6/26/2017
Project Location: 27546 Lacosse Street
Plan Check No.: PMT17-01911
BV Project#: 40017-039331.00
Project Description: PV Solar—Kevin Nickerson
Reviewer Date Hour Hourly
Rate Total
151 Plan Check Khoa Duong 6/26/2017 1.0 $110.00 $110.00
2nd Plan Check
3rd Plan Check
4th Plan Check
Final Approval: Khoa Duong 6/26/2017 1.0 $110.00 $110.00
Bureau Veritas North America,Inc.
1665 Scenic Avenue,Suite 200
Costa Mesa,CA 92626
M:714.431.4100 F:714.825.0685