PMT17-02254 City of Menifee Permit No.: PMT17-02254
_ 29714 HAUN RD.
�ACCEL/� MENIFEE, CA 92586 Type: Residential Mechanical
MENIFEE Date Issued: 06/30/2017
PERMIT
Site Address: 29535 ASH DALE WAY, MENIFEE, CA Parcel Number: 351-041-017
92587 Construction Cost: $5,000.00
Existing Use: Proposed Use:
Description of REMOVE AND REPLACE HVAC IN EXISTING LOCATION
Work:
Owner Contractor
JOSHUA HARDING KMA HVAC INC
29535 ASH DALE WAY 25920 IRIS AVE 13A-400
MENIFEE, CA 92587 MORENO VALLEY,CA 92551
Applicant Phone:8777178732
NATALIE LOPEZ License Number: 1023799
KMA HVAC INC
25920 IRIS AVE 13A-400
MORENO VALLEY, CA 92551
Fee Description QtV Amount fbl
Forced-Air or Gravity-Type Furnace or Burner 1 149.00
Air Handling/Condensing Units SFR 1 133.00
Building Permit Issuance 1 27.00
GREEN FEE 1 1.00
General Plan Maintenance Fee-Mechanical 1 14.10
$324.10
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_BIdg Pemiit 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 o I am exempt from licensure under the Contractor's State License Law for
Professions Code n�dj may license is in full force and effect.
1�/�^ ',4 the following reason:
License Class
,, ��tom+ License plo. is y l La�'1 By my signature below I acknowledge that,except for my personal residence
Expires_I I"W L I, _Signature •VAVI Jr,,; in which i must have resided for at least one year prior to completion of
•y 1 improvements covered by this permit.I cannot legally sell 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 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 www.leeinfo.ca.eov/calaw.html.
this permit is issued.
Policy R Date
❑I have and will maintain workers compensagon 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 owner's behalf.I have read this
number are:
application and the information I have provided is correct.I agree to comply
Carrier N f ( with all applicable city and county ordinances and state laws relating to
.1 1t ` building construction.I authorize representatives of this city or county to
Policy ff {L�11- l Expires enter the above identified property for inspection purposes.
(This section need not to be completed is the permits 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,
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 f wit comply with those provisions. Will the applicant or future building occupant handle hazardous material or a
mixture containing a hazardous material equal to or greater that the
Applicant Date amounts sipeciffied on the Hazardous Materials Information Guide?
WARNING:FAILURE TCI ECURE WORKER'S COMPENSATION COVERA IS ❑Yes r 0
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
CONSTRUCHON LENDING AGENCY ❑Yes Flo
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 bo dory of a school?
(Section 3097 Civil Code) ❑Yes 0
OWNER BUILDER DECLARATIONS I haver d 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&Safety Code,Section 25505 and 25534 concerning
Nazar a Is material reporting.
checkmark(s)I have placed next to the applicable item(s)(Section 7031.5 iYe No �/ 9
Business and Professions Code).Any city or county that requires a permit to Date 7� t
construct,alter,improve,demolish or repair any structure,prior to its PROPEWMMtR Oh 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(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).
01 MGfdn O9 managers who do the paint-disturbing work themselves orthrough their
❑I,as owner of the property,or my p�p0 ig,"ads 14 sole employees.For more Information about EPA's Renovation Program visit:
compensation,will do( )all of or( )�7 ) o the work,and the structure is www.epa.gov/lead or contact the National Lead Information Center at
not intended or offered for sale.(Section 704inis rfefessions 1-800-424LEAD(5323).
Code;The Contractors State License Law do ap ly 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 intende }��rd�'`ed for Certified Firm Name:
sale.If,however,the building or improve rr�®� � dti—i2'y@ar of Firm Certification No.:
completion,the Owner-Builder will have th 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:
❑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 & SAFETY PERMIT/PLAN CHECK APPLICATION
:rY l
Menifee
DATE (D iA PERMIT/PLAN CHECK NUMBER
TYPE: []COMMERCIAL RESIDENTIAL ❑MULTI-FAMILY ❑MOBILE HOME ❑POOL/SPA ❑SIGN
SUBTYPE: ❑ADDITI'ON []ALTERATION ❑DEMOLITION [-]ELECTRICAL ❑MECHANICAL
❑NEW ❑PLUMBING ❑RE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK \ 4 k L (1 U \pl' 6RIATC U)(Alio
PROJECTADDRESS Z fj2 r () L !J)
ASSESSOR'S PARCEL NUMBER ED5 I • 041- CT-1 LOT I 1 -1 TRACT
PROPERTY OWNER'S NAME Ij
ADDRESS /�
PHONE , ,, - 'L!{(pq EMAIL
APPLICANT NAME L,\1E .1 `^
ADDRESS "tO \ LS J - "F1 %Sfr 400 VAG +Nu [`V1
PHONE 11191 fto 0651 EMAIL WdkMkjfI0 VMAI 0 tlj�
CONTRACTOWS NAME 4 V OWNERBUILDER? ❑YES❑NO
BUSINESS NAME KN 1 P( kj %f r+C, tfJo `' G
l
ADDRESS t"W I1 LS � 67 #r Vk?J " AW O eW V 1r
PHONE - k ` %U fj;jj EMAIL 1CM A \�V CU NIA 1k\ 1.
CONTRACTOR'S STATEfLIC NUMBER lOti'yla� LICENSE CLASSIFICATION Cz
VALUATION$ �/ I(��`` II SO,FT \5,to L SQ FT
APPLICANT'S SIGNATURE ` V G AA1 e/ Z�2 DATE UP *b o
DEPARTMENT DISTRIBUTION CITY OF`MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN SMIP _y 0Z_ '
INVOICE PAID AMOUNT C
AMOUNT OCASH OCHECK# CREDIT CARD VISA/MC
PLAN CHECK FEES PAID AMOUNT --CASH ^CHECK# ^CREDITCARD VISA/MC
OWNER BUILDER VERIFIED OYES C NO DL NUMBER NOTARIZED LETTER C YES NO
City of Menifee Building&Safety Department 29714 Haun Rd. Menifee, CA 92586 951-672-6777
www.cityofinenifee.us Inspection Request Line 951-246-6213
^y m n a o O o 0 o T T D a D m
> >Las
10
j J ry N ei < O N a D O O O Z O A
N —
m
O y a C in
T m T c a W n
^
!p V N ,M n
a
2 O m o N C m
N O f3D W 3 = <
m O ti A W R v 2 d O
-
.Oi S O
n { v n
A A
m N N
S •v� � d
O O O = N
m 3 cNa N o.
� '• ° J J n ° V o a ^ D
0
o ^
00 J U
a
a
ry J J O m -
3 � c
A N <
r; ^ w o
m
m A = n
'm 3 m w 3
p 2 r
T D
N A p G �-
�
6
N 2 J f0 n, J N a H
u'
N. p N N W N
OFFI -
F "T ( 02 ? �5
p ?
d K K K d W N > 2 2 m 6 n i Z N Cf m T
S M
c Z Z Ni 3333 mm J p ^'
C CN f0 m V, O
N N
�I O O c' > a o 'er, 0 T
D 3 3 A � x £ m van oa m a 3aJ, a J r
o -p n A . a _, m D
n@od5 , z
m � p n
1 n n m m '� 0 0 > > m
o_ o N A '° 3 a 0- o o m 3 D 3 D 00
N O 91 d m u°. n F m o m J m J J m N
m p N A m
3 3
N o N FEE. > > o 'EUZ
2 e3i w 0< c T a m _ m p
O N o a c c ¢ c w >
MW `-� 3
o n N o w
p o H 5. m z , Mw' Q w F+ n
o o < ' = moo = c
0 7 (p
a
A 3 m =
07 H S 3 n a m o m J C w 7 D
CL
ur
(D .: o f
sm 3 m ' m o
m m w = N y3
m F o m a r V < CO
yN w w y N T N 2 O I D
o o o O 'y O
No N p . r p S a m n m 0 5, - m J
w F N w G
m VI m m
m m ! N m
n n a 3 d 3+ n
th -
O'O M T o a m J J
x
. n
a N I c N w C. ?. o 0
N ? N 3 3 w
o 2 3
of -
d
v S m
a
d m m
� 3cul
o
m
o O x m m
G) N m C
w
� O'
m O
V V m 0
m < T
N
A
ONl Vyi m � O � W T
n d o N n 30 � A d o F+ n -4o E o !'
^ N s o _ O a
m d 'i»^ NiN ma prj o in a w r.+ t+ V o'i t�n �
_ 50Z ° a
ry c
3 o
< Q m T r c S g m e
n
N u A m T 3 C N 3
MD ci v N ao ti m m a Vi !° rDD S p 9
N : Z
d N Y d N V C d ? O. O DI n f1
N S jp n H a ° O 1 01 0 O T
C
n m e d o » d w
n ,2 7 �`
N p n o ;4
�
4 m m '3
O. N
o N =
c o ¢ 3a n „
Ei
� 3 a m n CT 2 T j A
N n o m .�. 0 0
o n O 0
m o d N w 3 o O =
D
36 m A ff
�
S c -' � n
_. d 3 v
� A A N d � £ 3
3 � A
'n O n Oo a r N
�. p c V
O d 3 Ol �° m V n
E T
En
N > > a ? o a s � N w
d ydj A a
d c a >
N ° c n o N =
� .AS n aIw
a
G1 n n m A £ w ;4 E A
p a v 3 W
O
ON V~ N w T
KMA HVAC, INC.
LICENSE 1023799— B, C20
25920 Iris Ave. Ste13A-400
Moreno Valley Ca 92551
Bus. (951) 486-0337 Fax. (951) 486-0393
March 8, 2017
To who it may concern,
The following person is authorized to pull permits and business license on behalf of our
Company.
Natalie Lopez
Thank you for your assistance
Kenneth Telford
President
KMA HVAC, INC
California Contractors State License 1023799 0
2i
0
m
0
0
tee
NMI (
! � � ��� �� � � � — City & Safe of iy
I Y IVA1 \J Building 8 Safety Dept.
JUN 3 0 ?fo
RGCeived
CALIFORNIA ALL- PURPOSE
CERTIFICATE OF ACKNOWLEDGMENT
A notary public or other officer completing this certificate verifies only the identity
of the individual who signed the document to which this certificate AAWMI
and not the truthfulness, accuracy, or validity of that document. Building & safety De.a.
State of California y` }
JUN 3 0
County of � } Receive`:'
On I\UTY lij JM1i,�l,ZU'1I 1 �M Q 11 before me, MA NM UNM, I IVOt Q NMI �
ere msen nni�a r Mlle at officer)
personally appeared I�\ L 1� �1 ����� ,
who proved to me on the basis of satisfactory evidence to be the person) whose
named/are subscribed to the within instrument and acknowledged to me that
4Tk,)/she/they executed the same in 1 I her/their authorized capacity(IX, and that by
Sher/their signature0 4 on the instrument the person(', or the entity upon behalf of
which the person( 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.
�wJULIA AIRAM RODRIGUEZ
.v;, �= Commission No. 2187263 =
WITNESS my hand and official seal. _ NOTARY ion N . 21812
IFORNLA
Z / RIVERSIDE COUNTY
My Comm.Expires JANUARY 23,2021
of ry Public Signature (Notary Public Seal)
ADDITIONAL OPTIONAL INFORMATION INSTRUCTIONS FOR COMPLETING THIS FORM
This farm complies with current California statutes regarding notary wording and,
DESCRIPTION OF THE ATTACHED DOCUMENT (needed,should be completed and attached to the document.Acknowledgments
from other states may be completed for documents being sere to that state so long
as the wording does not require the California notary a violate California notary
law.
(Title or description of attached document) • State and County information must be the State and County where the document
L((p V1( P i 11 Z Q q — R signer(s)personally appeared before the notary public for acknowledgment.
1 ` 1 11 1 Il J I 1/ • Date of notarization must be the date that the signer(s)personally appeared which
(Title or description of attached document continued) must also be the same date the acknowledgment is completed.
• The notary public must print his or her name as it appears within his or her
Number of Pages I Document Date commission followed by a comma and then your title(notary public).
- Print the name(s) of document signers) who personally appear at the time of
notarization.
CAPACITY CLAIMED BY THE SIGNER • Indicate the correct singular or plural forms by crossing off incorrect fortes(i.e.
Wshe/they,is lare,)or circling the correct fortes.Failure to correctly indicate this
X Individual ( information may lead to rejection of document recording.
❑ Corporate Officer • The notary seal impression must be clear and photographically reproducible.
Impression must not cover text or lines. If seal impression smudges,re-seal if a
(Title) sufficient area permits,otherwise complete a different acknowledgment form.
El Partner(s) • Signature of the notary public must match the signature on file with the office of
Partner(s) the county clerk.
❑ Attorney-in-Fact Additional information is not required but could help to ensure this
❑ Trustee(s) acknowledgment is not misused or attached to a different document.
Other Indicate title or type of attached document,number of pages and date.
❑ Indicate the capacity claimed by the signer. If the claimed capacity is a
corporate officer,indicate the title(i.e.CEO,CFO,Secretary).
^n i version wvou v tiotaryclassp_s.con'3i:%„'( Rti5 Securely attach this document to the signed document with a staple.