PMT17-04296 City of Menifee Permit No.: PMT17-04296
29714 HAUN RD. Type: Residential Mechanical
<ACCEI J;�? MENIFEE, CA 92586
`"" 434"-. MENIFEE Date Issued:
12/05/2017
PERMIT
Site Address: 27020 LAMDIN AVE,MENIFEE, CA 92584 Parcel Number: 360-072-010
Construction Cost: $5,000.00
Existing Use: Proposed Use:
Description of REPLACE HVAC SYSTEM 4 TON, 80,000 BTU
Work:
Owner Contractor
JASON&DARLENE WITHERWAX SHALOM HEATING&AIR
27020 LAMDIN AVE 9191 VIA BALBOA CIR
MENIFEE, CA 92584 BUENA PARK,CA 90620
Applicant Phone:7148862021
BLANCA NOLASCO License Number: 967182
SHALOM HEATING&AIR
9191 VIA BALBOA CIR
BUENA PARK,CA 90620
Fee Description City Amount ISl
Forced-Air or Gravity-Type Furnace or Burner 1 149.00
Air Handling/Condensing Units SFR 1 133.00
Building Permit Issuance 1 27.00
GREEN FEE 1 1.00
General Plan Maintenance Fee-Mechanical 1 14.10
$324.10
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_BIdg 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).
Chapter)(commencing with section 7000)of Division 3 of the Business and ❑I am exempt from licensure under the Contmctofs State License Law for
Professions Code and my license is in full force and effect. the following reason:
License Class 0. —lo Lice n a-�I-\(p 't Z- By my signature below I acknowledge that,except for my personal residence
Expires �`V�3A S 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 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 www.leginfo.ca.gov/`c-alaw.htmi.permit is Issued.
Policy# Date
lave 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 o 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: application and the information I have provided Is correct.I agree to comply
Carrier Y\Q� with all applicable city and county ordinances and state laws relating to
pp�s
building construction.I authorize representatives of this city or county to
Policy# J4o� C 963oGlf Expires y Ll ( enter the above identified property for inspection purposes.
(This section need not to be completed Is the permit is for one-hundred Date
dollars($300)or less PROPERTY OWNER OR AUTHORIZED AGENT
o I cerllfy 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 became subject to the CITY BUSINESS LICENSE#
workers compensation laws of California,and agree that if I should became HAZARDOUS MATERIAL DECLARATION
subject to tfle'v *e scompe ation provisions of Section 3700 of the Labor
Code,I shall with comply ' those provisions. Will the applicant or future building occupant handle hazardous material or a
Applicant Date `L �� mixture containing a hazardous material equal to or greater that the
amounts specified on the Hazardous Materials Information Guide?
WARNING:FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS o Yes YNo
UNLAWFUL,AND SHALL SUBIECTAN 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($300,000),IN occupant require a permit for the construction or modification from South
ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR t Coas Air Quality Management District(SCAQMD)?See permitting checklist
IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES forguldZilges
rQua
CONSTRUCTION LENDING AGENCY ❑Yes o N`No
I hereby affirm that under the penalty of perjury there is a construction Will the proposed building or modified facility he 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 -AdNo
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" f de,Section 25505 and 25534 concerning
hazardo mated porting.
checkmark(s)I have placed nextto the applicable item(s)(Section 7031.5 oyes ANo
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 O EROR AUTF30RIZED 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 IRRPI
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 forthe 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
❑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.epa.gov/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 o An EPA Lead-Safe Certified Renovator will be responslble 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. ci No EPA Lead-Safe Certified Firm is required for this project bemuse:
❑I,as owner of the property am exclusively contracting with licensed
contractors to construct the project(Section 7044,Business and Pmfesslons
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.
e�� A
DATE: S PERMIT/PLAN CHECK NUMBER �}o�
TYPE: O'COMMERCIAL RESIDENTIAL O MULTI-FAMILY O MOBILE HOME O POOL/SPA OSIGN
SUBTYPE: O ADDITION XALTERATION O DEMOLITION O ELECTRICAL O MECHANICAL
O NEWf O PLUMBING O RE-ROOF NUMBER OF SQUARES
DESCRIPTION OF WORK 1 tUCQ n.0 04- Q C•-
Ao r N gip , n� 6-J 's
PROJECTADDRESS �OrOZC) LG-mC�L(\ �AL1Q ZIP :712 S2 r2
ASSESSOR'S PARCEL NUMBER L�OT(/.�l7 TRACT
OWNER NAME —16s�r\ Q to-i 1 f\-e
ADDRESS �
PHONE SZ.S C`�� C\ 13k9 ( EMAIL
APPLICANT NAME �'j.�G�CG� `U \CSC ,r� q
ADDRESS aLC\. V`�LL, �4-UL . �, � aI-p `
PHONE �� l d (\ �2� EMAIL S LJMY\L)L-C
CONTRACTOR'S NAME J c. , 1(-\,D vc,& C-O OWNER BUILDER? O YES ONO X
BUSINESS NAME � o n Q Ate—
ADDRESS
SPA
PHONE EMAIL
CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION
VALUATION$ S'.b00' SO,FT (��\ LSQFT
APPLICANT'S SIGNATURE DATE
CITY STAFF USE ONLY
DEPARTMENT DISTRIBUTION ACCEPTED B CITY OF MENIFEE BUSINESS LICENSE NUMBER
- /
BUILDING PLANNING ENGINEERING FIRE
PERMIT FEE (V SMIP GREEN
PLAN CHECK FEE INVOICE TOTAL ;5�;Jq I
OWNER BUILDER VERIFIED 0 YES 0 NO DRIVERS LICENSE# NOTARIZED LETTER 0 YES 0 NO
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