PMT18-00022 City of Menifee Permit No.: PMT18-00022
29714 HAUN RD. Type: Residential Re-Roof
�ACCEL/-> MENIFEE,CA 92586
MENIFEE Date Issued: 01/03/2018
PERMIT
Site Address: 26050 PINE VALLEY RD, MENIFEE, CA Parcel Number: 337-021-030
92586 Construction Cost: $12,000.00
Existing Use: Proposed Use:
Description of REMOVE EXISTING 2 LAYERS, REROOF W/TIMBERLINE COOL ROOF IN COASTAL SLATE
Work: CRRC#0676-0131
Owner Contractor
ROBERT ALLEN EKMAN ,
5550 LOGANBERRY LN
YORBA LINDA, CA 92887
Applicant License Number:
ROBERTALLEN EKMAN
5550 LOGANBERRY LN
YORBA LINDA, CA 92887
Phone:6262570509
Fee Description oft Amount ISl
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_Permit Template.rpt Page 1 of 1
CITY OF MENIFEE
LICENSED DECLARATION propertywho 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).
Chapter9(commencing with section 7000)of Division 3 of the Business and 1104 am exempt from licensure under the Contractor's State License Law for
Professions Code and my license is in full force and effect. the fallowing reason:
License Class License No. By my signature below I acknowledge that,except for my personal residence
Expires 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
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 worker's 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 lowing website:
by Section 3700 of the Labor Code,for the performance of work for which
this permit is issued. www.leelnfo.ca.xov/calaw.hvL
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 may my signature below I certify to each of the fallowing:I am the property
this permit is issued.My worker's 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 with all applicable city and county ordinances and state laws relating to
building construction.I authorize representatives of this city or county to
Policy# Expires enter the above identified property for inspection purposes.
(This section need not to be completed is the permit is for one-hundred 4 � Date /_ j 1
dollars($100)or less PROPERTY OWNER OR AUTHORIZED AGENT
,iTl certify that in the performance of the work for which this permit is issued,
I shall not emu[ov any persons in any manner so as to become subject to the CITY BUSINESS LICENSE#
worker's compensation laws of California,and agree that if I should become HAZARDOUS MATERIAL DECLARATION
subject to the worker's compensation provisions of Section 3700 of the Labor
Code,I shall forthwith comply with those ra r(s. Will the applicant or future building occupant handle hazardous material or a
Applicant --'ws ii-- Date 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 ❑Yes too
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 LABOR
CODE INTERTION,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- —
CONSTRUCTIONLENDINGAGENCY oyes ptao
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 -d'No
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
Contractor's License Law for the reason(s)indicated below by the California Health&Safety Code,Section 25505 and 25534 concerning
checkmark(s)I have placed nett to the applicable item hazardousmaterial reporting.
$)(Section 7031.5 oyes r�N6 ,l57 �/—l'v
Business and Professions Code).Any city or county that requires a permit to d� /jol /i Date
construct,alter,improve,demolish or repair any structure,priorto 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 Contractor's 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
D 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,wlil 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 Contractor's 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. ❑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 Contractor's 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.
APPLICATION& SAFETY PERM IT/PLAN CHECK
Menifee
5„
DATE /L —' 9 — Z 4 1 7 PERMIT/PLAN CHECK NUMBER 1 g�WV
TYPE: O COMMERCIAL PRESIDENTIAL O MULTI-FAMILY O MOBILE HOME 0 POOL/SPA 0 SIGN
SUBTYPE: O ADDITION O ALTERATION O DEMOLITION O ELECTRICAL O MECHANICAL
O NEW O PLUMBING ARE-ROOF-NUMBER OF SQUARES 36
DESCRIPTION OF WORK L
PROJECTADDRESS Z 9,43 �epk
ASSESSOR'S PARCEL NUMBER 3370 Z % 3CJ 3 LOT Z 3 TRACT
OWNER NAME 'vF /� /�L C F/✓ Lh m9l✓
ADDRESS S S �' GO(� +4/✓ry C Q 2 L Fli�� �02 y
PHONE Gz 6 Z .5-7 O'j a EMAIL OC,61-, 19, co//, ne c, �Z f
APPLICANT NAME i/, o Gc27 1574ar/r
ADDRESS
PHONE EMAIL
CONTRACTOR'S NAME i✓ /i7 OWNER BUILDER? (YES O NO
BUSINESS NAME
ADDRESS
PHONE EMAIL
CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION
VALUATION$ /Zi C SO FT L SQ FT
APPLICANT'S SIGNATURE DATE /Z_
1
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE GREEN I SMIP
INVOICE
AMOUNT .1O PAID AMOUNT 0CASH 0CHECK# OCREOITCARD VISA/MC
PLAN CHECK FEES PAID AMOUNT OCASH 0CHECK# OCREDITCARD VISA/MC
OWNER BUILDER VERIFIED OYES O NO DL NUMBER NOTARIZED LETTER G YES O NO
City of Menifee Building&Safety Department 29714 Haun Rd. Menifee, CA 92586 951-672-6777
www.cityofinenifee.us Inspection Request Line 951-246-6213
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