PMT17-04297 City of Menifee Permit No.: PMT17-04297
29714 HAUN RD. Type: Residential Plumbing
'tXCCELA_> MENIFEE,CA 9258E
MENIFEE Date Issued: 1 210 5/2 01 7
PERMIT
Site Address: 27810 GRAND AVE, MENIFEE, CA 92585 Parcel Number: 333-242-004
Construction Cost: $700.00
Existing Use: Proposed Use:
Description of REPLACE 40 GAL GAS WATER HEATER,SAME LOCATION GARAGE
Work:
Owner Contractor
JUDY HICKS INTER-CITY ENERGY SYSTEMS INC
27810 GRAND AVE - 1175 N DEL PLACE
MENIFEE,CA 92585 ONTARIO, CA 91764
Applicant Phone: 9097855075
TERESA DINTERMAN License Number:587709
INTER-CITY ENERGY SYSTEMS INC
1175 N DEL PLACE
ONTARIO,CA 91764 -
Fee Description Qtv Amount t51
Residential Water Heater 1 83.00 _
Building Permit Issuance 1 27.00
GREEN FEE 1 1.00
General Plan Maintenance Fee-Plumbing 1 4.15
$116.16
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.rpl 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 perjurythat I am under provisions of with a licensed contractors)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 Contractors State License Law for
Professions Code and my license is in full force and effect.
c� the following reason:
License Class o� Ucense . C d 77U J By my signature below I acknowledge that,except for my personal residence
Expires St� 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 Code,for the performance of work for which wwwpplicaftionis submitted
or.
this permit is issued.
Policy# Date
❑1 have 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 ❑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 an the property owners behalf.I have read this
number are: application and the information I have provided is correct.I agree to comply
Carrier (/ctY.� with all applicable city and county ordinances and state laws relating to
building construction.I authorize representatives of this city or county to
Policy# UtIC;i&/ -I�e—ll Expires enter the above identified property for inspection purposes.
(This section need not to be completed is the perm t is f r 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, O�i.r _O'
I shall not employ any persons In any manner so as to become subject to the CITY BUSINESS LICENSE# Act Lt
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 forthwith co ply with those pros. �! WIII the applicant or future building occupant handle hazardous material or a
Applicant�� Date 2"� mixture containing a hazardous material equal to or greater that the
amounts specif d on the Hazardous Materials Information Guide?
WARNING:FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS ❑Yes
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)7 See permitting checklist
IN SECTION 37060E THE LABOR CODE,INTEREST,AND ATTORNEYS FEES for guidelin
CONSTRUCTION LENDING AGENCY ❑Yes efNo
I hereby affirm that under the penalty of perjury there is a construction WIII 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 bounda of school?
(Section 3097 Civil Cade) ❑Yes
OWNER BUILDER DECLARATIONS I have read the Hazardous Material Information Guide and the SCAQMD
I hereby affirm under penalty of perjurythat I am exempt from the permitting checklist.I understand my requirements underthe State of
Contractors License Law for the reason(s)indicated below by the California Health& afety Code,Section 25505 and 25534 concerning
checkmark(s)I have placed next to the applicable Item(s)(Section 7031.5 hazardous erial reporting.
Business and Professions Code).Any city or county that requires a permit to oyes N�
�� /
construct,also alter,improve,demolisht for
permit
to file ,priartsta PROPE 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 Contractors State EPA RENOVATION,REPAIR AND PAINTING(FIRM
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 work
that distuified rbs
and comply with
than
Applicant for a permit subjects the applicant to a civil penalty of not more required practices.This Includes rental property owners and property
than($SDD). 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.eOp_a.eov/lead/lead or contact the National Lead Information Center at
not intended or offered for sale.(Section 7D44,Business and Professions 1-800424-LEAD(5323).
Code;The Contractors State License Law does not apply to an owner of a D 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. o No EPA Lead-Safe Certified Firm is required for this project because:
❑I,as owner of the property am exclusively contracting with licensed -
contractors to construct the project(Section 7044,Business and Professions
Cade: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
Mgr
DATE /a / PERMIT/PLAN CHECK NUMBER ' O
TYPE: C COMMERCIAL - RESIDENTIAL OMLILTI-FAMILY O MOBILE HOME O POOL/SPA C SIGN
SUBTYPE: O ADDITION ALTERATION O DEMOLITION O ELECTRICAL O MECHANICAL
O NEW PLUMBING C RE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK Q nLt,� y LAB 7� Sfr. L
1r� ✓
PROJECTADDRESS D
ASSESSOR'S PARCEL NUMBER LOT —D TRACT ( 1 SO'
OWNER NAME
ADDRESS �n7 L7 (9✓ - n L' /�,4�y S'
PHONE
APPLICANT NAME nn
ADDRESS S & jMvl D
PHONE EMAIL
CONTRACTOR'S NAME %✓ OWNER BUILDER? OYES NO
1
BUSINESS NAME
ADDRESS L /1.�17 a (9,�-�.r,`o. 91
PHONE !40q. WESo 7S' EMAIL 6 ,
CONTRACTOR'S STATE LIC NUMBER '51770 9 LICENSE CLASSIFICATION L'
VALUATION$ SO FT L SQ FT
APPLICANT'S SIGNATURE DATE
CUT STAFF U5E.ONLY
DEPARTMENT 0I5TRIBUTION CITY OF ME1NIF BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN I SMIP ✓ D(
INVOICE C5 PAID AMOUNT
AMOUNT ./' 1 C CASH OCHECK# 0CREDIT CARD VISA/MC
PLAN CHECK FEES PAID AMOUNT I I OCASH 0CHECK# OCREDITCARD VISA/MC
OWNER BUILDER VERIFIED OYES C 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.cityofinenlfee.us inspection Request Line 951-246-6213
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