PMT17-03064 City of Menifee Permit No.: PMT17-03064
29714 HAUN RD.
"ACCE LA-> MENIFEE, CA 92586 Type: Residential Re-Roof
MENIFEE Date Issued: 08/29/2017
PERMIT
Site Address: 26145 CHAMBERS AVE, MENIFEE, CA Parcel Number: 335-261-011
92586 Construction Cost: $10,890.00
Existing Use: Proposed Use:
Description of TEAR OFF ALL EXISTING LAYERS, INSTALL NEW COOL ROOF SHINGLES
Work: "CRRC#0890-0012*"
Owner Contractor
GLORIA AMMERMAN GARDNER ROOFING COMPANY
26145 CHAMBERS AVE 594 WEST SEVENTH STREET
MENIFEE, CA 92586 SAN JACINTO, CA 92382
Applicant Phone: 9516542794
LEE BLOOMER License Number: 528309
GARDNER ROOFING COMPANY
594 WEST SEVENTH STREET
SAN JACINTO, CA 92382
Fee Description gty Amount lEl
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_Pernit_Template.rpt Page 1 of 1
CITY OF MENIFEE
LICENSED DECLARATION property who builds or improves thereon,and who contracts for the projects
with a licensed contractors)pursuant to the Contractors State License Law).
I hereby affirm under penalty of perjury that I am under provisions of
Chapter9(commencing with section 7000)of Division 3 of the Business and ❑I am exempt from licensure under the Contractor's State License Law for
Professions Code and my license Is in full force and effect. the following reason:
License Class -7C� � License No. o� By my signature below I acknowledge that,except for my personal residence
Expires 12-20 (7 Signatu in which I 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
❑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 Cade,for the performance of work for which this permit is www.leglnfo.ca.gov/calaw.html
Issued.
Policy# -(� L� 3R Date
PROPERTY OWNER OR AUTHORIZED AGENT
o I have and will maintain workers compensation 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 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 U/ j with all applicable city and county ordinances and state laws relating to
building construction.I authorize representatives of this city or county to
Policy# / G Expires 2 l�tJ(� 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 workers compensation provisions of Section 3700 of the Labor
Code,I shall forthwit those provisions. Will the applicant or future building occupant handle hazardous material or a
Applicant ate "17 mixture containing a hazardous material equal to or greater that the
amoun ecified on the Hazardous Materials Information Guide'.
WAR .FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS ❑Yes kNo
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 forguidel es
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) ❑Yes INo
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 al Safety Code,Section 25505 and 25534 concerning
hazard 0 material reporting.
checkmark(s)I have placed next to the applicable item(s)(Section 7031.5 DYes KNo
Business and Professions Code).Any city or county that requires a permit to Date
construct,after,improve,demolish or repair any structure,prior to its PROPERTY OWN ER OR AUTHORIZED AG ENT
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(Chapter9(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.Anyviolation 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.gav/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. ❑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 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.
APPLICATIONBUILDING & SAFETY PERMIT/PLAN CHECK
DATE —1 — PERMIT/PLAN CHECK NUMBER
TYPE: []COMMERCIAL RESIDENTIAL MULTI-FAMILY ❑MOBILEHOME POOL/SPA ❑SIGN
SUBTYPE: ❑❑NEWITION❑PLU❑MBING[]ALTERATION []DEMOLITION UMB R OF 5❑QUA ES ICAECHANICAL
DESCRIPTION OF WORK 't- nWfare 1, 4U .
�.
L;It
y of Menifee
PROJECT ADDRESS '��"Ullding &Safety De
ASSESSOR'S PARCEL NUMBER - .p - 0�\ LOT TRACT
PROPERTY OWNER'S NAME ('(L(„
ADDRESS
2C� ,
eceived
PHONE (Q,�l H13 -({352 EMAIL
APPLICANT NAMQE'r C%'1VI�'vl,. _
ADDRESS _`�( 2 3
PHONE ( L EMAIL
CONTRACTOR'S NAME OWNER BUILDER? ❑YES NO
BUSINESS NAME C
ADDRESS S qZSJ
PHONE %�v ' L"I EMAIL (J
CONTRACTOR'S STATE LIC NUMBER 5 zeE3®C( LICENSE CLASSIFICATION
VALUATION $ t O • C FT 7j C. KD L SO FT II
APPLICANT'S SIGNATUR DATE
CITY STAFF USE ONLY
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN $MIP
INVOICE �,�' Q� 77''�� PAIDAMOUNT
AMOUNT �lJ IV '9D J CASH - CHECK# 'CREDITCARD VISA/MC
PLAN CHECK FEES PAID AMOUNT -- CASH -JCHECK# C/CREDITCARD VISA/MC
OWNER BUILDER VERIFIED •:'YES NO DLNUMBER NOTARIZED LETTER YES NO
City of Menifee Building&Safety Department 29714 Houn Rd. Menifee, CA 92585 951-672-6777
www.cityo fineni fee.us Inspection Request Line 951-246-6213
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