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PMT18-00265 City of Menifee Permit No.: PMT18-00265 29714 HAUN RD. Type: Commercial Alteration SRCCEL/? MENIFEE, CA 92586 ,sM r MENIFEE Date Issued: 03/27/2018 PERMIT Site Address: 29955 HAUN RD, MENIFEE, CA 92586 Parcel Number: 336-380-007 Construction Cost: $24,975.00 Existing Use: Proposed Use: Description of TENANT IMPROVEMENT INSTALL NEW COFFEE&HOT FOOD COUNTER, NEW FLOOR SINK AND Work: NEW PREP SINK, REPLACE WATER HEATER Owner Contractor CIRCLE K STORES, INC ISLAND PETROLEUM BUILDERS INC 255 E RINCON ST 1843 S CAMPUS AVE CORONA, CA 92879 ONTARIO, CA 91761 Applicant Phone: 9099239373 A&S ENGINEERING License Number: 776846 CA Fee Description gty Amount 181 Receptacle, Switch, Outlet& Fixture 1 116.00 Plumbing Fixtures and Vents, fixtures 2 116.00 Water Heater 1 83.00 Building Permit Issuance 1 27.00 Administrative Fee 74 74.18 Additional Plan Review Building 235 234.91 GREEN FEE 1 1.00 SMIP COMMERCIAL 1 7.00 New Construction Permit Fee 1 114.89 General Plan Maintenance Fee-Plumbing 1 9.95 General Plan Maintenance Fee-Electrical 1 5.80 General Plan Maintenance Fee-New 1 5.74 Construction $795.47 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 property who builds or improves thereon,and who contracts for the projects I herebyaffirm under with a licensed contractor(s)pursuant to the Contractors State License Law). penalty of perjury that I am under provisions of Chapter9(commencing with section 7000)of Division 3 of the Business and ❑I am exempt from licensure under the Contractor's State License Law for Professions Code and my license is in Mull farce and effect. the following reason: License Class C'jv Cis( 4241cens �Ip..����7`i 6 By my signature below I acknowledge that,except for my personal residence Expires L3 ;k> Signature in which I must have resided for at least one year prior to completion of WORKER'S COMPENSATION OECIARATION 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 fallowing 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 following website: by Section 3700 of the Labor Code,for the performance of work for which ww leeinfo.ca.eov/calaw.html. this permit is issued. w Policy p Date ❑I 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 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 1,0 with all applicable city and county ordinances and state laws relating to building construction.I authorize representatives of this city or county to Policy# W 50-200 L"'Expires enter the above identified property for inspection purposes. (This section need not to be completed is the permit is for 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, I shall not emolov any persons in any manner so as to became subject to the CITY BUSINESS UCENSEff worker's 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 c/o�,ply with those provisions. Will the applicant orfuture building occupant handle hazardous material or a Applicant Date 7� mixture containing a hazardous material equal to orgreaterthat the amounts specified an the Hazardous Materials Information Guide? WARNING:FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS ❑Yes ❑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 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 - --- - - CONSTRUCTIONLENDINGAGENCY ❑Yes ❑No 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 ❑No OWNER BUILDER DECLARATIONS I have read the Hazardous Material Information Guide and the SCAQMD 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 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 ❑No Business and Professions Code).Any city or county that requires a permit to Date construct,alter,improve,demolish or repair any structure,priorto its PROPERTYOWNER 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 Business and Professions Code)or that he or she is exempt from licensure The EPA Renovation,Repair and Painting(RRP)Rule requires contractors and the basis for the alleged exemption.Any violation of Section 7031.5 by receiving compensation far most work that disturbs paint in a ply with an Applicant for a permit subjects the applicant to a civil penalty of not more residence ra childcare facility includes a be rental property firms and comply with than($500). required practices.This includes rental property owners and property 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.eoa.eov/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 a ❑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. ❑No EPA Lead-Safe Certified Firm is required forthis 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. Island Petroleum Builders , Inc. 1843 S. Campus Ave Ontario CA 917601, Mailing Address: 7470 SVL Box, Victorville CA 92395 January 04, 2018 Attn: Applicable Regulatory Agencies I hear by authorize the following individuals with A&S Engineering to act on my behalf to obtain business license, permits and to sign permit applications for Island Petroleum Builders Inc. I am properly licensed as required by the state of California. The individuals are: • Ahmad Ghaderi • Ilse Jara Adolfo Gomez a Juan Sandoval ® Kevin Hurley Hoss Farzad Ben Caraveo a Robert Velasco I assume full responsibility under the law for the permits obtained by A&S Engineering. Should you have any questions or require further information please feel free to call my cell phone at (909) 228-0186 or my office at 909-923-9373. Sincerely Yours, <arleCoI�Iey CEO (909) 923-9373 — Fax (909) 923-9372 — License No. 776846 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 .n County of S/u� bem"'n0 ) On 1/q/,)-0 / before me, �1 ChtJ e SerraASo i-A y /U6(,_,-- (insert name and title of the officer) personally appeared 601ke ij , who proved to me on the basis of satisfactory evidence to be thd person(9)whose name(?)is/a�d subscfibed to the within instrument and acknowledged to me that he/sMe/tvey executed the same in his/h rfthOr authorized capacity), and that by his/h4rftf)i6fir signature on the instrument the person(, or the entity upon behalf of which the person(sryacted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph Is true and correct. MICNELE SERRANO WITNESS m hand and official seal. 910""')IMT COMAt.L 2089264 y NSAN B RNARMNGEIPoNNM N SAM BEAAARWMO COVMAT Comm.ESP.Nov.77,8818" SignatureIII-," (Seal)