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PMT17-03117 City of Menifee Permit No.: PMT17-03117 29714 HAUN RD. �CCEL/4�. MENIFEE, CA 92586 Type: Commercial Addition MENIFEE Date Issued: 10/3112017 PERMIT Site Address: 26100 MENIFEE RD,MENIFEE,CA 92585 Parcel Number: 331-260-018 Construction Cost: $58,484.00 Existing Use: Proposed Use: Description of IMPROVEMENTS AND ADDITIONS TO THE EXISTING EV CHARGING STATION. Work: Owner Contractor WENDELL KELLER 8631 RUSH ST.G04 ROSEMEAD,CA 91770 Applicant License Number: MENIFEE, CA Phone:5593261400 Fee Description ON Amount t$1 Services,Switchboards, Control Centers&Panels 1 116.00 Building Permit Issuance 1 27.00 Additional Plan Review Electrical 275 275.00 GREEN FEE 1 3.00 SMIP COMMERCIAL 1 17.00 General Plan Maintenance Fee- Electrical 1 5.80 $443.80 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_Pennit 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). j Chapter9(commencing with section 7000)of Division 3 of the Business and ❑I am exempt from licensure under the Contractors State License Law for (Professions Code and my license is in full force an �. the following reason: tLicense Cla By my signature below I acknowledge that,except for my personal residence zpir %Signature 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 -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 worker's 7044 of the Business and Professions Code,Is ava liable 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.IeRinfo.ca.Rov/caIaw.htmI.permit is issued. Policy# Date ❑I have and will maintain worker's compensation insurance,as required by PROPERTY OWNER OR AUTHORIZED AGENT section 3700 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 owners behalf.I have read this number ar�e:� /t,, y-�—, i{--�,f� Q �J rVplication and the information I have provided Is correct.I agree to comply Carder, \ lSr,�J�z��/�4"Cb-1 I Irl ]11�-f tW Ith all applicable city and county ordinances and state laws relating to i, bu ding constructlon.I authorize representatives of this city or county to Policy# Expires �i `� enter the above identified property for inspection purposes. l (This section need not to be completed is the permit is for r1he-hundred I Date dollars($100)or less ROPERTY 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 i9.any manner so as to become subject to the CITY BUSINESS LICENSE# workers ithM pensati ws o Cal fp rnia,and agree that if I should become HAZARDOUS MATERIAL DECLARATION object toe worke s compe satidn provisions of Section 3700 of the La or \\de,I shcomply 'h hose provisions. rt Will the applicant or future building occupant handle hazardous material or a A�Rlicant Date © / mixture containing a hazardous material equal to or greater that the t ` amounts s_pee ed on the Hazardous Materials Information Guide? WARNING:FAILURE O SECURE WORKER'S COMPENSATION COV RAGE IS ❑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 require a permit for the construction or modifization from South ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR Coast Air Quality Management District(SC construction or See permitting checklist IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES for guidelines CONSTRUCTION LENDING AGENCY o Yes 6..W� 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 agencyfor the performance of the work which this permit is issued outer bounds f a school? (Section 3097 Civil Code) o Yes OWNER BUILDER DECLARATIONS I have read the Hazardous Material Information Guide and the SCAOMD I hereby affirm under penalty of perjury that l am exempt from the per mittingc Ist�l understand my requirements under the State of Contractors License Law for the reason(s)indicated below by the je rnia ea[th 8,Sal Code,Section 25505 and 25534 concerning al checkmark(s)I have placed next to the applicable Item(s)(Section 7031.5 u m ial r 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 p W OR A [ZED 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(RRP) 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 in 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.aov/lead or contact the National Lead Information Center at not intended or offered for sale.(Section 7D44,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 forthis 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: in 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. 1IILLDDfB,IJ6r?iyV �lfll(�Idl���llhf//1?U�yl©�I��C<N�LLII�cJIITf1001tiJ ems, Menifee DATE PERMIT/PLAN CHECK NUMBERl " ri—V 5 ( I TYPE: EXCOMMERCIAL ❑RESIDE TIAL ❑MULTI-FAMILY ❑MOBILE HOME ❑POOL/SPA ❑SIGN SUBTYPE: ❑ADDITION ffALTERATION ❑DEMOLITION ELECTRICAL ❑MECHANICAL [—]NEW ❑PLUMBING FIRE-ROOF-NUMBEROFSQ.UARES 1 DESCRIPTION OF WORK C Ao nS IL v is .PROJECTADDRESS �,(0106 raensfee e and n/^� R I ✓i I 1 ASSESSOR'S PARCEL NUMBER 7j'�j)- � - 0 J'j LOT TRACT PROPERTY OWNER'S NAME I� SS 1 e 'e kx ADDRESS lY� `ush�] nn/n� y,. F-Mf e PHONE � ' 3�p• " IWVI� EMAIL APPLICANT NAME J� /; /� I,, ADDRESS �J C `S , STL • ajoVfSI C11 g3lU1j_ PHONE ( SSff)?Ja-(12 - 1/400 EMAIL ra C C baA-eNr- wm CONTRACTOR'S NAME OWNERBUILDER? ❑YES[NO BUSINESS NAME ADDRESS PHONE EMAIL CONTRACTOR'S STATES LIC NUMBER LICENSE CLASSIFICATION VALUATION$ 5 D SO FT L SO,FT APPLICANT'S SIGNATURE DATE DEPARTMENT DISTRIBUTION CITY OF WNIFEE BUSINESS LICENSE N BER BUILDING PLANNING ENGINEERING FIRE GREEN SMIP INVOICEyi PAID AMOUNT AMOUNT p • OCASH 0CHECK# OCREDITCARD VISA/MC LPLAN CHECK FEES PAIDAMOUNT 0CASH 0CHECK# OCREDITCARD VISA/MC NER BUILDER VERIFIED OYES O NO DL NUMBER NOTARIZED LETTER O YES O NO City of Menifee Building&Safety Department 29714 Houn Rd. Menifee, CA 92586 951-672-6777 www.cityafinenifee.us Inspection Request Line 951-245-6213 i Perera Construction & Design, Inc. Lic. N B-585965 October 17, 2017 City of Rosemead CL To whom it may concern; U This letter will serve as authorization for Miguel Ponciano to pull permits, licenses, and any LU other pertinent documentation related to any of our projects for Southern California Edison's U PEV Electrical Charge Ready Stations, regardless of City, within the State of California. LLL If you have any questions, please feel free to contact this office. 0 Sincerely, Tony e uez President Vice President of Operations Enclosure: California Contractors License Certificate of Workers Compensation City of M n'fee e I Building Dept. OCT 3 1 2017 Received ____. ._ _. _.._ nw,. ow.ono 1AA 11 sn 1 Pv OnO AAA IA19 1 Allf Fr 9n9 AAA❑AAS CALIFORNIA CERTIFICATE OF ACKNOWLEDGMENT 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 ) County of I i On 1 G �L� before me (here insert name and title oi the officer) personally appeared _ t r 0 who proved tome on the basis of satisfactory evidence to be the person(s)whose name(s) is/are subscribed to LU j the within instrument and acknowledged to me that he/she/they executed the same in his/her/their (� authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s)acted,executed the instrument. LL I certify under PENALTY OF PERJURY under the laws of the O State of California that the foregoing paragraph is true and correct. JOHN KING WITNESS my hand and official seal. o` COMM. #2163563 zz tr Notary Public-California o z San Bernardino County Corn.Expires .26,2021 Signature (Seal) r�r• Optional Information Although the information in this section is not required by late,it could prevent fraudulent removal and reattachment of this ackno:vledgment to an ir•I unauthorized document and tray prove useful to persons relying on the attached document. Description of Attached Document ' The preceding Certificate of Acknowledgment is attached to a document Method of signer Identification titled/for the purpose of Proved to me on the basis of saiislaclory evidence: forts) aedble v tines,'<' -----" — - -- —" "--- -- - - --- ' Notarial event s detailed in notaryjoumal on: containing _ _ pages,and dated aoe x Entry The signer(s) capacity or authority is/are as: Notary contact: Individual(s) Other _-__.. ... _ Attorney-in-=act J Curpoiate Officers) +"I'_mi ral Agncrts) 5pneg9 rhumtrrinq:i- -_—__ TmeT, -- Guardian/Conservator Partner-Limited/General City Of M@nifee Trustees) J other: Building Dept. representing: OCT 3 ) 2u;r Receive o i _., . � �.. .. _ -.�. ' l a::ry c. 1..-••. r n., • r :" .o- a n_:. ;n u. " ,. _L Y v v✓._..� Perero Construction & Design, Inc. Lic.H B-585965 �A 0 V Uj L LL State Of California - ..CONTRACTORS STATE LICENSE BOARD ACTIVE LICENSE -- 585965 CORP 1 PERERA CONSTRUCTION & DESIGN 1 INC _ B ® �� 01/31/2018 www.esib.ca.gov 1 4- i City Of Menifee Bu*ft Dept. ` OCT 3 1 Received 2890 inland Empire Blvd.Suite 102 Ontario,CA 91764 1 Ph:909.484,6350 1 Fx:909.484.3439 1 Acct.Fx:909.484.0885 PERECON-01 LHEMMERS CERTIFICATE OF LIABILITY INSURANCE DAM 1113 012 0 1 YY) 11/30/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemerd(s). PRODUCER License#0757776 cosracr NAPE: L sands Jones-Hemmers Redlands,CA-HUB International Insurance Services Inc. PNDNE FAx 470 East Highland Ave uC N Ell; 909)379-1333 AID,No: 909 533-2266 Redlands,CA 92373 ADDRIESS:lysandra.hemmers@hubinternational.com INSURER(S)AFFORDING COVERAGE NAICN INSURERA:The Continental Insurance Compan 35289 INSURED INSURERS:National Fire Insurance of Hartford 120478 Pereira Construction&Design Inc. INSURER C:State Compensation Insurance Fund of California 35076 2890 Inland Empire Blvd. Suite 102 INSURER D:RSUl Indemnity Company 122314_ Ontario,CA 91764 INSURER E: _ INSURER F. COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INRR TYPED INSURANCE INNS)LISWV RI POLICYNUMBER POLICY EFF POucYIXP 1 YYIDO NYn1D UNR$ A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,D00,0 A 100,0 CLAIMS-MADE OCCUR X I X I4014312735 12/01/2016 12/01/2017_RANiA$ES f_R0l nencet S MEDEXP(Anyoneperam) $ 15,0 0 •PERSONAL~ q,ADV INJURY Is 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE ' 1IT 2,000,00 11 POLICY' X JEC7 `! LOG I PRODUCTS-COMPIOP AGO i 5 2,000,00 OTHER: I I $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMB � Ea accident $ 1,D00,000 A X ANY AUTO X X 6023564166 112101/2016112101/2017 BODILY INJURY(Perperw) S ALLOWNED i SCHEDULED — -------- _AUTOS AUTOS BODILY INJURY(Per acotlenq S X HIRED AUTOS X NOOSWNED I PROPERTY DAMAGE Per accident S X UMBRELLA LIAB AlOCCUR EACH OCCURRENCE $ 5,000.00 B EXCESS LVl9 CLAIMS-MADE! 6023564183 12/01/2016 12/01/2017 AGGREGATE' $ 5,000,00 DED I X RETENTION$ 10,000 S WORKERS COMPENSATION I X STATUTE OETRH ___ AND EMPLOYERS'LIABILITY C ANYOFFICERIMEETOREXCLUDR/E%ECUTIVE rYI'N�' X 908026516 1210112016 1210112017: E.L.EACH ACCIDENT $ 1,OOD,000 (Mandatory inN )EXCLUDED? IJIN/A l. (Mandatory in NH) I 'E.L DISEASE-EA EMPLOYEE 1rODD,"0 H yes,tlescnbe under DE SCRIPTIONOFOPERATIONSbelow I E.L.DISEASE-POLICY LIMIT 1,0001) D Commercial Umbrella NHA241499 12/01/2016 12/01/2017 Occurrence 14,000,0 A Equipment Floater 034236604 12101/20161 12/01/2017 Max Limit 50,0 I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Re: SAMPLE FOR INFORMATION PURPOSES ONLY" SAMPLE SAMPLE SAMPLE FOR INFORMATION PURPOSES ONLY are Additional Insured on General Liability per CNA75079XX 0115 attached where required by written contract. Primary Non-contributory wording,Waiver of Subrogation and General Aggregate Per Project apply where required by written contract per CNA74705XX 0115 attached. Auto Additional Insured and Waiver of Subrogation applies per CNA63359XX 4112,including Primary Non-contributory wording Where required by written contract. Waiver of Subrogation on Workers Compensation applies per 10217 0714 attached.$5,000,000 Excess Liability follows Form to the$5,000,000 Umbrella Liability,General Liability,Automobile Liability and Workers Compensation/Employers Liability. SEE ATTACHED ACORD 101 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE d00Tf ffW D IN Peres Construction l Design Inc-(FYIISAMPLE) ACCORDANCE WITH THE POLICY PROVISIONS. t+iLy l71 IVItlI 171 2890 Inland Empire Blvd Ste 102 Ontario,CA 91764 BuNding Dept. AUTHORIZED REPRESENTATIVE OCT 3 ©1988-2014 ACORD CORPORpT^'ON. All rights reserved ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Kece ived