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)