PMT17-02231 City of Menifee Permit No.: PMT17-02231
29714 HAUN RD.
�ACCELA? MENIFEE, CA 92586 Type: Residential Electrical
MENIFEE Date Issued: 06129/2017
PERMIT
Site Address: 27601 VAN BUREN AVE, MENIFEE,CA Parcel Number: 329-221-003
92585 Construction Cost: $500.00
Existing Use: Proposed Use:
Description of MAIN PANEL UPGRADE 125A
Work:
Owner Contractor
JOSE FLORES ,
27601 VAN BUREN AVE
MENIFEE,CA 92585
Applicant License Number:
MENIFEE, CA
Fee Description Qtv Amount rEl
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 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 perjurythat 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 exemptfrom licensure under the Contractors 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 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
❑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 ,,vyvyv,leeinfo.ca:eov/calaw.h[ml.
this permit Is issued.
Policy q MQr1nl kg yj CLOlU Cc2 Date 6/ZCt I 1
v
PROPERTY OWNER OR AUTHORIZED AGENT
❑I have and will maintain worker's compensation insurance,as required by
section 3700 of the Labor Cade,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 owner's 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 9 Expires enter the above identified property for inspection purposes.
9 /'7
(This section need not to be completed is the permit Is for one-hundred ),�r`t'I �[ Y L�)�2 Date 6 s.�
dollars($100)or less
PROPERTY OWNER OR AUTHO ZED 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 If
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. Will 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 15 ❑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($100,000),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 ❑No
I hereby affirm that underthe penalty of perjury there is a construction Will the proposed building or modified facility be within 1000feet 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 ❑No
OWNER BUILDER DECLARATIONS I have read the Hazardous Material Information Guide and the SCAQMD
permitting checklist.I understand my requirements under the State of
I hereby affirm under penalty of perjury that I am exempt from the
Contractors License Law for the reason(s)indicated below by the California Health Safety Code,Section 25505 and 25534 concerning
hazardous material
reporting.
checkmark(s)i have placed nett to the applicable Rem(s)(Section 7031.5 oyes ❑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 IRRP)
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 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
❑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 1-900-424-LEAD(5323).
Code;The Contractor's State License Law does not apply town 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:
P<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.
PERMIT/PLANBUILDING & SAFETY APPLICATION
...�.k.. Menifee
DATE PERMIT/PLAN CHECK NUMBER
TYPE: O COMMERCIAL O RESIDENTIAL O MULTI-FAMILY 0 MOBILE HOME O POOL/SPA O SIGN
SUBTYPE: O ADDITION O ALTERATION O DEMOLITION i ELECTRICAL O MECHANICAL
O NEW O PLUMBING O RE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK t �' v
C O f EL'Building & Sa y Pf.
PROJECTADDRESS O t
ASSESSOR'S PARCEL NUMBER 3aq-.Qak-(005 LOT TRACT JUN 2 9 201
OWNER NAME V.Vei t
ADDRESS 226 t V
PHONE C4 S1 � 3 CAI EMAIL
APPLICANT NAME Y \
ADDRESS V
PHONE Clog, 16 fsg- EMAIL
CONTRACTOR'S NAME OWNER BUILDER? B YES O NO
BUSINESS NAME
ADDRESS
PHONE EMAIL
CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION
VALUATION$ 1500 p 0 SO,FT L SQ FT
APPLICANT'S SIGNATURE-- fZ DATE Z
CITY STAFF USE ONLY
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN SMIP
INVOICE 1 PAIDAMOUNTJM AMOUNT OCASH 0 CHECK# 0CREDIT CARD VISANIC
PLAN CHECK FEES PAIDAMOUNT 0CASH 0CHECK# 0CREDIT CARD VISA/MC
OWNER BUILDER VERIFIED OYES O NO DLNUMBER NOTARIZED LETTER 0 YES O NO
City of Menifee Building&Safety Department 29714 Houn Rd. Menifee, CA 92586 951-672-5777
www.cityo finenifee.us Inspection Request Line 951-246-6213
City of Menlfee
June 28,2017 Building & Safety Dept.
Jose Francisco Flores JUN 2 9 2017
27601 Vanburen Avenue
Menifee, CA 92585 Rece ed
I,Jose Francisco Flores(with Driver's License Number F8393328), owner of the property
stated above.The reason for this letter is to grant Mrs. Susana Rodriguez with Driver's License
08393482 permission for her to obtain permits to change the electrical panel for the above
stated address.
If you need any question of need additional information please do not hesitate to contact me on
the above address.
Respectfully,
Jo Fir Ra rscsco Flores
A notary public or other officer completing this certificate verifies only the identity of the
individual who signed the document, to which this certificate is attached, and not the
truthfulness,accuracy,or validity of that document.
State of California
County of Los Angeles
On June 28,2017 before me,Robert Veea,Notary Public,personally appeared Jose Francisco
Flores who proved to me on the basis of satisfactory evidence to be the person(s)whose name(s)
is/are subscribed in the within instrument and acknowledged to me that he/she/they executed the
same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the
instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the
instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the
foregoing paragraph is true and correct.
;igEal
S t and and official seal.
:
My Commission Expires: Anril 14.2021
ROBERTVEGA
[NOTARY SEAL] Notary Public—Callfomia
`- Los Angeles County
Commisslon N21B686g —
My Comm.Expires Apr 14 2021