PMT17-04558 City of Menifee Permit No.: PMT17-04558
29714 HAUN RD.
�/-�CCiii MENIFEE,CA 9258E Type: Residential Plumbing
f1rt' 9fW''— MENIFEE Date Issued: 1 212 712 01 7
PERMIT
Site Address: 28655 SHADY BROOK DR,MENIFEE, CA Parcel Number: 340-250-040
92584 Construction Cost: $2,848.00
Existing Use: Proposed Use:
Description of REPLACE 50 GAL GAS WATER HEATER, SAME SIZE AND LOCATION IN GARAGE
Work:
Owner Contractor
EVERETTE THOMPSON AFFORDABLE WATER HEATERS AND PLUMBING
28655 SHADYBROOK DR INC
MENIFEE, CA 92584 28358 CONSTELLATION ROAD#698
Applicant Phone: 8553459087
GREGORY GUERRY License Number.627368
AFFORDABLE WATER HEATERS AND PLUMBING INC
28358 CONSTELLATION ROAD#698
VALENCIA, CA 91355
Fee Description ON Amount f51
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
$116.15
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_Permk_Template.rpt Page 1 of 1
CITY OF MENIFEE
ICENSED DECLARATION property who builds or improves thereon,and who contracts for the projects
with a licensed contractor(s)pursuant to the Contractors State License Law).
I hereby affirm under penalty of perjury that 1 am under provisions of
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 my is in full force and effect. the following reason:
Ucense Class LAG CrJtnZJ.Nr�License No. Lz:�: By my signature below 1 acknowledge that,except for my personal residence
Expires 61-30-I K Signature —� in which I must have resided for at least one year priorto completion of
improvements covered by this permit.I cannot legally sell a structure that 1
WORKER'S COMPENSATION DECLARATION have built as an owner-builder if it has not been constructed in its entirety by
o 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 forworkers 7044 of the Business and Professions Code,is available upon requestwhen
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.leeinfo.ca.eov/calaw.html.
this permit is issued.
Policy It Date
)i(p 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 9 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 polity Pwner 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 T,.,� c.o S- 4-r..,t (i-2cC F with all applicable city and county ordinances and state laws relating to
building construction.I authorize representatives of this city or county to
Policy# ryC&&So'iLUJ:Zc21 Expires g9 I. -r7 ( -L enter the above identified property for inspection purposes.
(This section need not to be completed is the permit is for one-hundred Date i 7
dollars($100)or less ROPERTY OWNER OR AUTHORIZED AGENT
o I certify that in the performance of the work for which this permit is issued,
I shall not emnlov any persons in any manner so as to become subject to the CITY BUSINESS LICENSE It _2�Z' 7
workers compensation laws of California,and agree that if I should become HAZARDOUS MATERIAL DECLARATION
subject to the workers compensation provjsions of Section 3700 of the Labor
Code,I shall forthwith comply with those provisions. Will the applicant or future building occupant handle hazardous material or a
mixture containing a hazardous material equal to or greater that the
Applicant Date (�'Z-Z!gF- amounts specified on the Hazardous Materials Information Guide?
WARNING:FAILURE TO SECURE WORKER' COMPENSATION COVERAGE IS Dyes jONo
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 for guidelines
CONSTRUCTION LENDING AGENCY oYes aglo
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) Dyes jLNo
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 reasons)indicated below by the California Health al Safety Code,Section 25505 and 25534 concerning
hazardous material reporting.
checkmark(s)I have placed next to the applicable items)(Section 7031.5 oYes polo
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 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 IRRP)
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 icensure 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
❑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.epa.aov/lead or contact the National Lead Information Center at
not intended or offered for sale.(Section 7044,Business and Professions 1-BOD-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 r iPgL{¢rvM"Menifee
property provided that the improvements are not intended or o r ft.1� Certified Firm Name:
sale.If,however,the building or improvement is sold within one Wokg Dept.
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. DEC 2 7 201 7 O No EPA Lead-Safe Certified Firm is required for this project because:
o I,as owner of the property am exclusively contracting with licensed GU f
contractors to construct the project(Section 7044,Business and Professions
Code:The Contractors State License Law does not apply to„'an v r 1 ve ur project does not comply with EPA RRP rule please fill out the RRP
nowledgement.
BUILDING & SAFETY PERMIT/PLAN CHECK APPLICATION
A-- Nlerifee
DATE PERMIT/PLAN CHECK NUMBER
TYPE: O COMMERCIAL RESIDENTIAL O MULTI-FAMILY O MOBILE HOME O POOL/SPA O SIGN
SUBTYPE: O ADDITION O ALTERATION O DEMOLITION O ELECTRICAL O MECHANICAL
O NEW PLUMBIN/G�r OO RE-ROOF-NUMBER OF SQUARES
DESCRIPTION OF WORK - .
II S 41 o n r0i e
PROJECTADDRESS 2 S \Q S S f) C
ASSESSOR'S PARCEL NUMBER 5L40 'QG50 ' LOT _4 TRACT `J
PROPERTY OWNER'S NAME S
ADDRESS Z f p K 0r
PHONE S 1 qS EMAIL
APPLICANT NAME �! //�� ((��
ADDRESS MG a DI"
PHONE `�'�-.�(�C. a►�p�,� EMAIL
CONTRACTOR'S NAME -F OWNER BUILDER? O YES ONO
BUSINESS NAMEhk��Lk `
ADDRESSqt3�SSG AA 0%,
PHONE 45�-JLJs-QII,0LAq EMAIL C/ W c6
CONTRACTOR'S STATE LIC NUMBER !dL'�3kJ� LICENSE CLASSIFICATION
VALUATION$ 2 I S -1 ff - SQ FT L SQ FT
APPLICANT'S SIGNATURE - DATE % Z - Z. tZ' l
OTY STAFF USE OJNLY
DEPARTMENT DISTRIBUTION i CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNINGG� ENGINEERING FIRE GREEN SMIP
II J.I�INVOICE PAID AMOUNT
AMOUNT O CASH OCHECK# OCREDIT CARD VISA/MC
PLAN CHECK FEES PAIDAMOUNT 0CASH 0 CHECK# 0CREDIT CARD VISA/MC
OWNER BUILDER VERIFIED O YES O NO DL NUMBER NOTARIZED LETTER O YES O NO
City of Menifee Building&Safety Department 29714 Houn Rd. Menifee, CA 92585 951-672-6777
www.cityofinenifee.us Inspection Request Line 951-246-6213
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