PMT17-02515 City of Menifee Permit No.: PMT17-02515
29714 HAUN RD.
�-WC- LA> 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: $103,840.00
Existing Use: Proposed Use:
Description of PERMANENT FOUNDATION FOR REPLACEMENT OF NEW MANUFACTURED HOME 1512 SO FT
Work: SERIAL#PER037809CA A/B, INSIGNIA#RADII 526496/7
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 Qtv Amount ISI
Manufactured Permanent Foundation 1 240.72
Permit Fee 1 27.00
$267.72
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 building 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 ❑I am exempt from Iicensure under the Contractor's State License Law for
Professions Code and my license is in full force and effect. the following reason:
License Class 16 U a No. By m si nature below I acknowledge that,except form ersonal 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.)cannot legally sell a structure that 1
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 Cade,for the performance of work for which
this permit is issued. www.leeinfo.ca.gov/alaw.html.
Policy# Date
W<ave and will maintain worker's com ensa PROPERTY OWNER OR AUTHORIZED AGENT
p pon insurance,as required by
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 worker's 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.S`� -c- Come ✓/S_ (ti y/%• with all applicable city and county ordinances and state laws relating to
�j building construction.I authorize representatives of this city or county to
Policy# G—/ 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 employ any persons in any manner so as to become subject to the CITY BUSINESS LICENSE#
worker's compensation laws of California,and agree that if I should become HAZARDOUS MATERIAL DECLARATION
subject to the work Jos compel provisions of Section 3700 of the Labor
Code,I she fo ith cam y th se ovisions. --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:FJULLft&TO SECURE WORKER'S COMPENSATION COVERAGE IS o 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 37060E THE LABOR CODE,INTEREST,AND ATTORNEYS FEES for guidelines
CONSTRUCTION LENDING AGENCY ❑Yes ❑No
1 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 ❑No
OWNER BUILDER DECLARATIONS I have read the Hazardous Material Information Guide and the SCAQMD
I hereby affirm under penalty of perjury that l am exempt from the permitting checklist.I understand my requirements underthe State of
Contractor's 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 DYes ❑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 Contractor's 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 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 Perm it 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
❑1,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.Kov/lead or contact the National Lead Information Center at
not intended or offered for sale.(Section 7044,Business and Professions 1-80G-424-LEAD(5323).
Code;The Contractor's 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:
❑1,as owner of the property am exclusively contracting with licensed
contractors to construct the project(Section 7044,Business and Professions
Code:The Contractor's 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.
1
.. a '.
DATE PERMIT/PLAN CHECK NUMBER �a'JIC,7
TYPE: O COMMERCIAL RESIDENTIAL O MULTI-FAMILY O MOBILE HOME O POOLJSPA OSIGN
SUBTYPE: O ADDITION O ALTERATION O DEMOLITION O ELECTRICAL O MECHANICAL
(L a.t,.i„n ,K1 NEW O PLUMBINGG O RE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK 'Ma ✓II;t FD/:NA&/' E-[QnV j�RM• tcJY1 E(.
m �J
PROJECTADDRESS 7151 &R a 1/ /y�/�
ewPer- ea 9 58
ASSESSOR'S PARCEL NUMBER 36 L4 - p- ooq LOT TRACT,
PROPERTY OWNER'S NAME rt G✓ 3arx4avaI4 Avop
ADDRESS a' 9 ,pm Creex d C6 eO n ,
PHONE �,tjI-`1/0-2603 EMAIL • Gab V MDO ' COM
APPLICANT NAME r� V_/
ADDRESS
PHONE l l5/I �� ... 5-��� EMAIL
i
CONTRACTOR'S NAME �, 0 S OWNER BUILDER? O YES YNO
BUSINESSNAME
ADDRESS $ , 0111SY3
PHONE ��� � .��3 ��"� J EMAIL EIFJ-Vti pp ;ry / DM
CONTRACTOR'S STATE LIC NUMBER 13394 LICENSE CLASSIFICATION
VALUATION$ P/}� L �l SQ FT `y L SQ FT
APPLICANT'S SIGNATURE AJA' DATE
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS UCENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN SMIP
INVOICE PAID AMOUNT
AMOUNT vCASH O CHECK# OCREDIT CARD VISA/MC
PLAN CHECK FEES PAIDAMOUNT 0CASH 0 CHECK M OCREDITCARD VISAIMC
OWNER BUILDER VERIFIED OYES O NO DL NUMBER NOTARIZED LETTER O YES 0 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
City Df pgertitee
Buiwing Dept STATE OF CALIFORNIA NUMBER:
BUSINESS,CONSUMER SERVICES AND HOUSING AGENCY pp ,y
DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT
']UL 19 2017 MANUFACTURED OFC OUS AN STANDPRO RDS
AIVI
REI1TURER CERTIFICATE OF ORIGIN
❑ CHECK IF THIS IS A DUPLICATE MCO-ENTER ORIGINAL MCO NO.
MANUFACTURED HOME OR MULTIFAMILY MANUFACTURED HOME NUMBER OF
SFD(SINGLE FAMILY DWELLING) ❑ MFMH(MULTIFAMILY MANUFACTURED HOME) TRANSPORTABLE SECTIONS
COMMERCIAL MODULAR:
OCCUPANCY GROUP
MANUFACTURER NAME: MANUFACTURER LICENSE NUMBER:
MANUFACTURER ADDRESS: SUGGESTED RETAIL PRICE:
(Sfre* _ _ - (City) (State) (zip)
MANUFACTURER TRADE NAME: MODEL NAME AND/OR NUMBER: DATE OF MANUFACTURE:
NAME OF DEALER OR TRANSFEREE(OWNERSHIP TRANSFERRED TO): CALIFORNIA DEALER NUMBER OR DATE OF TRANSFER:
.. _ .. - TRANSFEREE DESIGNATION:
DEALER OR TRANSFEREE ADDRESS:
(StfAet) - - - - - (City) (State) - (Zip)
INVENTORY CREDITOR NAME:
INVENTORY CREDITOR ADDRESS:
_._. __.. -
(Stteet) -- - - (City) - - (State) (Zip)
SECTION MANUFACTURER SERIAL NUMBER HCD INSIGNIA OR HUD LABEL NUMBER LENGTH WIDTH WEIGHT
76 INCHES INCHES POUNDS
TRANSPORTER NAME:
TRANSPORTER ADDRESS:
(Street)' - (city) (State) (�7)
DESTINATION FOR UNIT DESCRIBED ABOVE:
State L
I cer(ITy L7tder penalty ofperjuryundei Ilse fawe ofilie State of California that the above facts are true and correct.
Executed on at
I*140m) - '- -. (Qarl (county) (State)
SIGNATURE OF AUTHORIZED AGENT:
DISTRIBUTION: ORIGINAL(PINK) FORWARD TO THE INVENTORY CREDITOR,UNLESS THERE IS NONE,THEN FORWARD TO THE PURCHASER(DEALER OR TRANSFEREE).
COPY 1(WHITE) FORWARD TO THE DEPARTMENT AT Pq.8OX 1828,SACRAMENTO,CA 95612-1828.WITHIN FIVE(5)DAYS OF RELEASE.
COPY 2(YELLOW) DELIVER TO THE TRANSPORTER TTACCOMPANY THE UNIT TO ITS DESTINATION,
COPY 3(GOLDENROD) TO BE RETAINED BY THE MANUFACTURER.
HCD 483.0-Side 1 (Rev.07/15)