PMT17-02510 City of Menifee Permit No.: PMT17-02510
29714 HAUN RD. Type: Pool/Spa -Residential
'�ACCELA MENIFEE, CA 92586
MENIFEE Date Issued: 07/18/2017
PERMIT
Site Address: 28733 SUNRIDGE LN, MENIFEE, CA Parcel Number: 372420-030
92584 Construction Cost: $30,000.00
Existing Use: Proposed Use:
Description of INGROUND POOL&SPA,504 SF
Work:
Owner Contractor
TOBIAS KOUROUBACALIS
28733 SUNRIDGE COURT
MENIFEE, CA 92584
Applicant License Number:
MENIFEE, CA
Fee Description Div Amount($)
Swimming Pool/in-Ground Spa 1 467.00
Building Permit Issuance 1 27.00
GREEN FEE 1 2.00
SMIP RESIDENTIAL 1 4.00
General Plan Maintenance Fee-Electrical 1 23.35
$523.35
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 carted 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 Templatesiot 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 YJ'a�, exempt from 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 l must have resided for at least one year prior to completion of
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
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 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 p ��� Date
O I have and will maintain workers compensation Insurance,as required by ,PROPERTY OWNER OR AUTHORIZED AGENT Y
section 3700 of the Labor Code,for the performance of the work for which "r 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# Expires enter the above identified property for inspection purposes. �p
(This section need not to be completed is the permit is for one-hundred A Date I
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 employ any persons in any manner so as to become subject to the CITY BUSINESS LICENSE p
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
Cade,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 IS O Yes O 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 requires permit for the construction or modification from South
ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR Coast Air Quality Management District(SCAQMD7 See permitting checklist
IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES for guidelines
CONSTRUCTION LENDING AGENCY O Yes o 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) O Yes ❑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&Safety Code,Section 25505 and 25534 concerning
hazardous material reporting.
checkmark(s)I have placed next to the applicable item(s)(Section 7031.5 OYes O 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 IRRPI
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
O 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.eav/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 O 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. O No EPA Lead-Safe Certified Firm is required for this project bemuse:
❑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.
ka"'?
Menifee
DATE --'Z a I'l PERMIT/PLAN CHECK NUMBER - daP..S O
TYPE: []COMMERCIAL RESIDENTIAL ❑MULTI-FAMILY ❑MOBILE HOME ❑POOL/SPA ❑SIGN
SUBTYPE: [-]ADDITION ❑ALTERATION []DEMOLITION ❑ELECTRICAL ❑MECHANICAL
❑NEW [-]PLUMBING [-IRE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK GU )VX tv.. G (- 5P C6 `1 10ri✓
PROJECTADDRESS � a1 T fv l r(� -
ASSESSOR'S PARCEL NUMBER '6qa-L,,=- Z LOT TRACT
PROPERTY OWNER'S NAME (A(LUAa P,i, City of Menife
pt.
ADDRESS qq+2 Q33 Fj12 — 1
PHONE '4 '�f)q XA�P,� EMAIL {� '
APPLICANT NAME Pr G"'t-�� ^ aeec,,
ADDRESS �u-1-
PHONE �L� IS ,J L� EMAIL
CONTRACTOR'S NAME OWNER BUILDER? S❑NO
BUSINESS NAME
ADDRESS
PHONE EMAIL
CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION
VALUATION$ w Y-- SO FT L SO FT
APPLICANT'S SIGNATURE DATEOil
f TZU�
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN -' SMIP
INVOICE PAID AMOUNT
AMOUNT OCASH OCHECKtt O CREDITCARD VISA/MC
PLAN CHECK FEES PAIDAMOUNT I OCASH ()CHECK# 0 CREDIT CARD VISA/MC
OWNER BUILDER VERIFIED OYES O NO DL NUMBER NOTARIZED LETTER O YES O NO
City of Menifee Building&Safety Deportment 29714 Houn Rd. Menifee, CA 92586951-672-6777
www.cityofinenifee.us Inspection Request Line 951-246-6213
Tobias Kouroubacalis City of Menifee
Building & Safety Dept.
28733 Sunridge Court
Menifee, Ca 92584 JUL 18 2017
July 12, 2017
Received
City of Menifee
Building Department
RE: Authorization for Paul Choi to submit engineering specs. and request a pool building permit on my behalf
Please allow Paul Choi to submit my pool engineering plans and request the proper permit(s) in order for me
to start the building process of my pool at my above address in Menifee, Ca.
Sincerer
�2Lir+LL�
Tobias Kouroubacalis
28733 Sunridge Court
Menifee, Ca 92584
951-377-7186
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189
C
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 I )
County of 8j.,1PA.xU6 1 )
On 7.13.' 9%01-7 before me,. 6( -n L( &alwwie, , ii cu j ithilc-
Date J Here Insert Name and Title of the Officer
personally appeared �o��� /<&uA"AeAcd�
Name(s)of Signer(s)
who proved to me on the basis of satisfactory evidence to be the person(s) whose names) is
s bscribed to the within instrument and acknowledged to me that -e"/tl;ey executed the same In
I
is r/their authorized capacity(iee,and that b is r/their signatur`e�s}on the instrument the person(s),
he entity upon behalf of which the person*-a ed, 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.
SHARON K.SUON000RE WITNESS my hand and official seal.
Notary Public-California
Riverside County
Commission Y2199726 $I nature
My Comm.Ex piresJun 26,2U21 g
Signature of Notary Public
Place Notary Seal Above
OPTIONAL
Though this section is optional, completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document: Leo--e r
Document Date: 2 urz Number of Pages:
Signer(s) Other Than Named Above:
Capacity(ies) Claimed by SIi�gn��ers)
Signer's Name:T0ID&& I,fTIAI'176t6LCeJ15 Signer's Name:
❑Corporate Officer — Title(s): ❑Corporate Officer — Title(s):
❑ Partner — ❑ Limited ❑General ❑ Partner — ❑ Limited ❑ General
❑Individual ❑Attorney in Fact ❑ Individual ❑Attorney in Fact
❑Trustee ❑Guardian or Conservator ❑Trustee ❑Guardian or Conservator
❑Other: ❑ Other:
Signer Is Representing: Signer Is Representing:
02016 National Notary Association •www.NationalNotary.org•1-800-US NOTARY(1-800-876-6827) Item#5907
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