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PMT17-02724 City of Menifee Permit No.: PMT17-02724 29714 HAUN RD. Type: Residential Re-Roof <ACCECA-'? MEN IFEE, CA 92586 MENIFEE Date Issued: 08/03/2017 PERMIT Site Address: 28819 BROKEN ARROW CIR, MENIFEE, Parcel Number: 388-060-023 CA 92584 Construction Cost $20,220.00 Existing Use: Proposed Use: Description of REMOVE EXISTING TILE SHINGLES, RELAY PAPER, RELAY EXISTING TILES Work: Owner Contractor APRIL FISCHER PETERSEN-DEAN INC 28819 BROKEN ARROW CIRCLE 39300 CIVIC CENTER DRIVE MENIFEE, CA 92584 FREMONT, CA 94538 Applicant Phone:5103716500 JENNY ENCISO License Number:468117 PETERSEN-DEAN INC 39300 CIVIC CENTER DRIVE FREMONT, CA 94538 Fee Description Qtv Amount ISI Building Permit Issuance 1 27.00 Inspections not specified 98 98.00 GREEN FEE 1 1.00 General Plan Maintenance Fee-Building 1 4.90 $130.90 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_Templale.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 70D0)of Division 3 of the Business and ❑I am exempt from licensure under the Contractor's5tate License Law for Professions Code and my license is in full force and effect. 1 1 the following reason: License Class- (', A-o License No. 1 I By my signature below l acknowledge that except for my personal residence Expires A_ I 201q 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 ❑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 appliation 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 4 1 have and will maintain worker's compensation insurance,as required by PROPERTY OWNER OR AUTHORIZED AGENT section 370D of the Labor Code,for the performance of the work for which o 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 t _\ with all applicable city and county ordinances and state laws relating to v-� `� building construction.l authorize rep esentatives of this city or county to Policy#s��q�� Expires 4- -MZF 1�T5— enterflea ve ide tiff property o inspection purpoos�se��s.�� --��J dolls section need not to he completed is the permit is fprone-hundred Dated�� _ dollars($100)or less pR ERTY OZALITHbR12MAGENT o 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 worker's compe ation provisions of Section 3700 of the Labor Code,l shall forthwith mplylO rthosep visions. Will the applicant or future building occupant handle hazardous material or Applicant lI Date mixture containing a hazardous material equal to or greater that the amounts s cified on the Hazardous Materials Information Guide? WARNING:FAILURE TO URE WORKER'S COMPENSATION COVERAGE IS ❑Yes o 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(SC construction or See p anon from checklist IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES for Coast Ai.r i as CONSTRUCTION LENDING AGENCY oYes 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 bou/flary of a school? (Section 3097 Civil Code) o Yes �Tu No OWNER BUILDER DECLARATIONS I have read the Hazardous Material Information Guide and the SCAQMD I hereby affirm under penalty of perjury that 1 am exempt from the permitting checklist.I understand my requirements under the State of Contractor's License Law for the reason(s)indicated below by the California Health&Safe Code,Se n 25505 and 25534 concerning checkmark(s)I have placed next to the applicable item(s)(Section 7031.5 hazardous aterial rep ing. Business and Professions Code).Any city or county that requires a permit to oyes o construct,alter,Improve,demolish or repair any structure,prior to its - Date issuance,also requires the appliant for the permit to file a signed statement PROPERTY W( 8DR AU !)RIZED AGENT that he or she Is licensed pursuant to the provisions of the Contractor's State EPA REt OVAT10 REPAIR AND PAINTING IRRpJ 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 inapre-1978 and the basisfor themitsdects th appyn. int to ionof5ection of not o residence or childcare facility to be RAP-certified firms and comply with than n($5Appl0 ).fora permit subjects the applicant toacivil 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.eov/lead or contact the National Lead Information Center at not intended or offered for sale.(Section 7044,Business and Professions 1-800424-LEAD(5323). Code;The Contractor's State License Law does not apply to an owner of oAn EPA Lead-Safe Certified Renovator will be responsible for project property who,through employees'or personal effort,builds or improves the p p J 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. D No EPA Lead-Safe Certified Firm Is required for this project because. 01,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 If your project does not comply with EPA RRP rule please fill out the RAP Acknowledgement. PPLIC 1 f MIenifee DATE Ion PERMIT/PLAN CHECK NUMBER -1 TYPE: ❑COMMERCIAL RESIDENTIAL ❑MULTI-FAMILY ❑MOBILE HOME ❑POOL/SPA El SUBTYPE: []ADDITION ❑ALTERATI ❑DEMOLITION ❑ELECTRICAL ❑MECHANICAL ONEW [:]PLUMBING `oRE-ROOF-NUMBER OFSQUARESA_ } DESCRIPTION OF WORK 1 1 PROJECTADDRESS21119 "G r1^�2 City of Menifee ASSESSOR'S PARCEL NUMBER � 5{—(�I Q[}" �.p�J LOT TRACT BUliding & Safety D Pt. PROPERTY OWNER'S NAME� I\ �w 7 ADDRESShj�j V PHONE �j 3 D EMAIL celve'. 1 APPLICANT NAME ADDRESS 3 is PHONE 5 1 ' U EMAIL CONTRACTOR'S NAME ,Se WNER BUILDER? ❑YES NO BUSINESS NAME ADDRESS G1 // I ��i PHONE ,J G `Q ' A n D EMAIL � 1�� 11� CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION31 VALUATION $ �I� 172 V SQ L SQ FT APPLICANT'S SIGNATURE DATE n 2 U Ordr.Y�' d3 8)J`17 DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER BUILDING PLANNING � (ENGINEERING FIRE GREENINVOICE SMIP AMOUNT ` : .- . PAID AMOUNT ,nO "l O CASH ()CHECK# U CREDIT CARD VISA/MC PLAN CHECK FEES PAID AMOUNT v CASH O CHECK# O CREDITCARD VISA/MC OWNER BUILDER VERIFIED 0 YES 0 NO DL NUMBER NOTARIZED LETTER 0 YES O NO City of Menifee Building&Safety Department 29714 Houn Rd. Menifee, CA 92586 951-672-6777 www.cityofinenifee.us Inspection Request Line 951-246-6213