PMT17-02514 City of Menifee Permit No.: PMT17-02514
29714 HAUN RD.
'q%CCEL/? MENIFEE, CA 92586 Type: Mobile Home
MENIFEE Date Issued: 08/22/2017
PERMIT
Site Address: 27151 BORGARDUS RD, MENIFEE, CA Parcel Number: 384-110-004
92584 Construction Cost: $103,940.00
Existing Use: Proposed Use:
Description of SITE PREP FOR REPLACEMENT OF NEW MANUFACTURED HOME 1512 SO FT
Work: SERIAL#PER037809CAA/B, INSIGNIA#RAD1526496/7
Owner Contractor
CHRISTOPHER SANDOVAL&CHELSEA K DAVID GOODWIN MASONRY
KOUTHOOFD 798 HARDING
13296 WAGON CREEK RD HEMET,CA 92543
Applicant Phone: 9513235719
JAMES MATTHEWS License Number.633914
DAVID GOODWIN MASONRY
798 HARDING
HEMET,CA 92543
Fee Description Dot Amount(E)
Manufactured Residential Site Prep 1 196.00
Permit Fee 1 27.00
$223.00
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
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 Contractors State License Law for
Professions Code and my license is in full force and effect the following reason:
License Class Lice a No.
_ _ _ __ __ _ey my signature belowlacknowledge that,except for mypersonai residence
i
Expires Signature in which l 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
❑1 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.
Policy# Date
19-Kave 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: ��1 application and the Information I have provided is correct.I agree to comply
Carrier,�`fri"1'ti co vHP /12s_ o-'� with all applicable city and county ordinances and state laws relating to
/ building construction.I authorize representatives of this city or county to
Policy# —/ 7 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 I should become HAZARDOUS MATERIAL DECLARATION
subject to the work, s com a ��n provisions of Section 3700 of the Labor
Code,I sha fo i h corn p i th se visions. —7 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:FAIL TO SECURE WORKER'S COMPENSATION COVERAGE 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($100,000),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)7 See permitting checklist
IN SECTION 37060E THE LABOR CODE,INTEREST,AND ATTORNEYS FEES for guidelines
CONSTRUCTION LENDING AGENCY ❑Yes ❑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
permitting checklist.I understand my requirements under the State of
I hereby affirm under penalty of perjurysn(s)in I am exempt from the California Health&Safety Code,Section 25505 and 25534 concerning
Contractors License Law for the reason(s)indicated below by the hazardous material reporting.
checkmark(s)I have placed next 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 fRRP)
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($500). managers who do the paint-disturbing work themselves or through their
❑I,as owner of the property,or my employee with wages as their sole employees.For more information about EPA's Renovation Program visit:
compensation,will do( )all of or( )portion of the work,and the structure is www.eoa.Roy/lead or contact the National Lead Information Center at
not intended or offered for sale.(Section 7044,Business and Professions 1-800-424-LEAD(5323).
Code;The Contractors State License Law does not apply to an owner of a ❑An EPA Lead-Safe Certified Renovator will be responsible for this project
property who,through employees'or personal effort,builds or improves the
property provided that the improvements are not Intended or offered for Certified Firm Name:
sale.if,however,the building or improvement is sold within one year of Firm Certification No.:
completion,the Owner-Builder will have the burden of proving that it was
not built or improved for the purpose of sale. o No EPA Lead-Safe Certified Firm is required for this project because:
❑I,as owner of the property am exclusively contracting with licensed
contractors to construct the project(Section 70",Business and Professions
Code:The Contractors State License Law does not apply to an owner of a if your project does not comply with EPA RRP rule please fill out the RRP
Acknowledgement.
DATE PERMIT/PLAN CHECK NUMBER
TYPE: 0 COMMERCIAL RESIDENTIAL 0- MULTI-FAMILY '3 MOBILE HOME C POOL/SPA "SIGN
SUBTYPE: (, ADDITION ^ALTERATION O DEMOLITION O ELECTRICAL O MECHANICAL
Et A, 0 NEW O PLUMBING C% RE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK �g
PROJECTADDRESS Me ii e'c eq R 58
ASSESSOR'S PARCEL NUMBER 3$y -11 o- 00q LOT TRACT
PROPERTY OWNER'S NAME l y . K AcP of
ADDRESS L to ,Z
PHONE q5l-7I6)-�1603 EMAIL Gavl cL1106 Cary)
APPLICANT NAME r� ,W „(
ADDRESS _7 t ,! 2S Y 3
PHONE )� ��3 S7� EMAIL --
CONTRACTOR'S NAME S OWNER BUILDER? O YES ;M-NO
BUSINESS NAME f2kVk, 7 i%
ADDRESS A 6� 5
PHONE (�,5 ,�y3 ^s� I / EMAIL SIirV d0 , yy I i,
CONTRACTOR'S STATE LIC NUMBER L3- LICENSE CLASSIFICATION
VALUATION$ JQSSQ FT _ 2 L SQ FT
APPLICANT'S SIGNATURE f✓ DATE
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN SMIP
INVOICE PAID AMOUNT
AMOUNT OCASH <%CHECK# '3 CREDIT CARD VISA/MC
I I
PLAN CHECK FEES PAIDAMOUNT OCASH OCHECKN 0 CREDIT CARD VISAIMC
OWNER BUILDER VERIFIED 0 YES G 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
Riverside County Fire Department Office of the Fire Marshal Section
Gdl,n DWI011ge 7793L&IM tIR&s RdsI201ralm DesertCA9v IN RhIIhtade CA A9, Ph9221141311M(701863-88816 WFax3126N 863-7072
Fire Department Clearance/Release
Date:f•L 1 1
To: ccadson@cityofinenifee.us;brivera@cityofinenifee.us;mbinnall@ckyofinenifee.us
Fax:
Tract/Parcel Map#:
Permit/Lot#: ENlT 2—D2r✓14�n2c�lcJl��s1
Job Site Address: I ` �b R/4 Svc rz? .
11 Final For Recordation
Release For Building Permit(s)
r1 Shell Final Only(No Tenant)
F1 Final For Occupancy
n Release For Residential Sprinkler Installation
n Building Plan Check Fees Paid, Water Requirement Met-If water applicable
rl Building Plan Check Fees Not Paid
fl Residential Sprinkler Plan Check Fees Paid
r1 Residential Sprinkler Plan Check Fees Not Paid
n Other Fees
fl Fees Not Required
If you should have any questions, please contact the appropriate Riverside County F r ectiort Planning office for
further assistance.
V Authori "g Signature
or R Felaa?;e
��l N�1, I tvSPEGTI Off 7c- s � yA g �
Print Name
FMm C-Rer.890 Sn vi6
County of Riverside
DEPARTMENT OF ENVIRONMENTAL HEALTH
www.rivcoeh.org
OWTS INSPECTION CARD
APN: O —w i Permit No.: ON to(0 Site Address: G� J t ��; Qt'gQr�(C{ /Q pQ City: 4�1�(Nf0 Zip: `/�
72,�W
V
To schedule an inspection please call ❑ Riverside 951-955-8980 or ❑ Indio 760-863-7570
All cancellations/reschedules must be received prior to Sam on the day of inspection or additional fees will apply.
OWTS Components Date Re-Inspection Inspector
of Inspection Date Initials
Septic Tarlk 2Z�D
ach Linej-)3ed o;Z q
Seepage Pits
eptic Tank Abandonmen
Sewer Lateral of
Box
- iser
Effluent Filters
Fnal Inspection
TO BE POSTED AT708 SITE IN PLAIN VIEW
EPO-55(REV 6/16)