PMT18-01747 City of Menifee Permit No.: PMT18-01747
29714 HAUN RD.
- / MENIFEE, CA 92586 Type: Commercial Alteration
MENIFEE MENIFEE Date Issued: 09/04/2018
PERMIT
Site Address: 29881 ANTELOPE RD,Suite#102, Parcel Number: 340-020-042
MENIFEE, CA92584 Construction Cost: $274,990.52
Existing Use: Shell Retail Proposed Use: Restaurant
Description of TENANT IMPROVEMENT FOR CAFE RIO MEXICAN GRILL,TO INCLUDE ARCHITECTURAL,
Work: MECHANICAL, ELECTRICAL AND PLUMBING
Owner Contractor
MENIFEE LAKES PLAZA, LLC
3636 BIRCH ST SUITE 200
NEWPORT BEACH,CA 92660
Applicant License Number:
CLARK COMMERCIAL DEVELOPMENT, INC.
, CA
Phone:7149281166
Fee Description ON Amount ISl
Tenant Improvement Building 1 696.00
Services,Switchboards, Control Centers&Panels 2 366.00
Services,Switchboards, Control Centers&Panels 1 283.00
Receptacle, Switch, Outlet&Fixture 78 501.00
Plumbing Fixtures and Vents, fixtures 14 171.00
Gas System 1 116.00
Water Heater 1 83.00
Sewer 1 150.00
Hood Served by Mechanical Exhaust 3 657.00
Building Permit Issuance 1 27.00
Additional Plan Review Building 1,265 1,264.96
GREEN FEE 1 11.00
SMIP COMMERCIAL 1 77.00
New Construction Permit Fee 1 1,264.96
General Plan Maintenance Fee-New 1 63.25
Construction
$6,731.17
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 staled,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 hereby affirm under penalty of perjury that I am under provisions of wither licensed contractor(s)pursuant to the Contractors State License Law).
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 license is in full force and effect. /-''77 the following reason:
License Class . nse No. S y!-I� By my signature below I acknowledge that,except for my personal residence
Expires /D 1 ti 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 DECIARATION 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 far which
this permits Is issued. www.le info.ca. ov calaw.html. q
Policy k /0 3 Z. Date /
❑I have and will maintain workers compensation insurance,as required by PROPERTY OWNER OR AUTHORIZED AGENT
section 37DO 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 on the property owners behalf.I have read this
number are: A application and the information I have provided is correct.I agree to comply
n
Carrier / T Cc o r d with all applicable city and county ordinances and state laws relating to
11 building construction.I authorize representatives of this city or county to
Policy ft 0 -I 2 Expires I -/ " ZC r U 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 AG ENT
❑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 become subject to the CITY BUSINESS LICENSE 4
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 comply with those provisions. Will the applicant or future building occupant handle hazardous material or a
Applicant Date mixture containing a hazardous material equal to or greater that the
amounts s9ecified on the Hazardous Materials Information Guide?
WARNING:FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE 15 o Yes }y No
UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER 70 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 guici lines
CONSTRUCTION LENDING AGENCY ❑Yes IN.N.
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
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
ardous material reporting.
checkmark(s)I have placed next to the applicable item(s)(Section 7031.5 N
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 RTY OWNER OR KUTHORIZED AG NT
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 LRRPI
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 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( I all of or( )portion of the work,and the structure is www.epa.goy/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 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
Code: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.
FIRST RELEASE FORM
T.95 rumble-928-37 Rd • P.O. Box 8300 • Perris, Ca 92572-8300 /� m �w TEaR++
c Yv MUNICIPAL
T.951-928-3777 • F.951-928-6177
emwd.org OKT.CT
Requesting Agency: City ofMenifee—email:brivera@cityofinenifee.us,,ccarlson@cityofinenifee.us
APPLICANT INFORMATION:
Business Name: Cafti Rio Mexican Grill
Service Address: 29881 Antelope Rd Ste 102
Contact Name: Terry Loock
Contact Phone: (801)441-5010 ext. Contacte-mail: 800ck@caferio.com
REQUESTING AGENCY AND APPLICANT PLEASE NOTE:
This "FIRST RELEASE" Is being Issued to allow applicant to pull permits with your agency and DOES NOT constitute a
release for Certificate of Occupancy.
Subsequent EMWD "FINAL RELEASE"or "CLEARANCE" is to be requested by the applicant noted above and will be
submitted to your office prior to your agency Issuing the Certificate of Occupancy.
Other.
Your cooperation in this matter is greatly appreciated. It is extremely Important that these procedures are followed for
EMWD to meet federal and state requirements.
Eastern Municipal Water District has reviewed and accepted the following as of De/29/2018
H Application for Service (date)
®Waste Discharge Application
® Plans
EMWD is to provide: ®WATER and/or ®SEWER SERVICE(5). The provisions of service are contingent upon the applicant
completing the necessary arrangements in accordance with EMWD rules and regulations:
FEES REQUIRED:
❑ New Business Fees Due Call(951)928-3777 ext 2082 for more information. t�
❑ Source Control Fees Due Call(951)928-3777 ext 6203 for more information. O
INSPECTION REQUIRED:
❑ Sewer Lateral Call(951)928-3777 ext4372 48 hours prior to backfilling to schedule.
❑ Backflow,Prevention Call(951)928-3777 ext4938 to schedule.
® Rough Plumbing Call(951)928-3777 ext 6203 48 hours prior to backfilling to schedule.
❑ Interceptor Installation Cali(951)928-3777 ext 6203 to schedule.
INTERCEPTOR STATUS:
❑ No Interceptor is required.
❑ Current interceptor is acceptable. Size:
® New interceptor to be installed. Size: 1,500
IF ANY INSPECTIONS ARE REQUIRED: Eastern Municipal Water District must inspect the service connection(s), the installed
backflow prevention, and/or the plumbing prior to backfilling to verify that the accepted plans have been followed and that
requirements have been met. If you have any questions,please call EMWD at(951)928.3777 extension 2081.
Z2 ? Kiel Maples New Business Development 08/29/2018
EMWD Representative Signature Printed Name Department Date
NBD.002
REV.12/05/16
Paradise Winters
From: Matt Clark <matt@clarkcd.com>
Sent: Tuesday, September 4,2018 10:42 AM
To: Paradise Winters
Subject: FW: Plan Approval Notice for"Cafe Rio - 29881 Antelope Road, Menifee"
Attachments: EMWD First Release- City.pdf
Importance: High
Below is the email I received from health about approval.And, I've attached EMWD's release. Please call me ASAP if you
need anything else.
MATT CLARK
CLARK COMMERCIAL DEVELOPMENT, INC.
1719 W. ST. GERTRUDE PL.
SANTA ANA. CA 92704
(714) 928-1 166 TEL.
(81 5) 425-8762 EEAX
MATT@CLARKCD.COM
PLEASE NOTE OUR NEW ADDRESS
From: Lojeski,Jeff<JLojeski@RIVCO.ORG>
Sent:Tuesday, May 1, 2018 7:23 AM r
To: Matt Clark<matt@clarkcd.com>
Subject: Plan Approval Notice for"Cafe Rio-29881 Antelope Road, Menifee"
Hello Matt:
The plans that you submitted for the new"Cafe Rio" in Menifee are approved and are ready to be picked up at our
Hemet office(800 S.Sanderson Ave., Hemet, CA). Be aware that you'll need to submit will serve and grease interceptor
waiver/clearance letters from EMWD at time of plan pick-up.
�r
0NM1=N rA(�,�.
Jeff Lojeski,REHS
W yy = Enviromnental.Health Specialist III
Plan Check—Hemet Office
District Environmental Services Division
PO \o� Phone#: 951-766-2824
G~� OF aN��`9 E-mail:jloieski(2rivco.org
.. www.rivcoeh.org
_........................................_...................._._......_......._............................................ ..._...........-...............---.................--......_...................................._..............._..............._..........................................
.Confidentiality Disclaimer
;This email is confidential and intended solely for the use of the individual(s)to whom it is addressed.The information contained in this message may be
;privileged and confidential and protected from disclosure.
If you are not the author's intended recipient,be advised that you have received this email in error and that any use,dissemination,forwarding,printing,or
1
County of Riverside
y DEPARTMENT OF ENVIRONMENTAL HEALTH
FOOD ESTABLISHMENT PLAN APPROVAL NOTICE
Service Request# 41450
Project Name Date 5/1/18
Cafe Rio Address 29881 Antelope Road, #48 Menifee CA
Plans Submitted by Matt Clark -
Owner SAA Address SAA Phone 714-928-1166
Phone SAA
The plans are now,ap
proved subject to the conditions listed below and the attached compliance sheet.
1) Provide will serve and grease interceptor waiver/clearance lett ers r r
2) Provide an air balance report for all Type I exhaust hoods, at time of finalfmspechonUo
bo
MONO
CONSTRUCTION INSPECTIONS: Contact the Plan Checker for a Preliminary Inspection when construction is
ww
approximately 80% complete, with plumbing, rough ventilation, and rough equipment installed. Request for
inspection should be made at least five(5)working days in advance.
A FINAL INSPECTION MUST be made upon completion of ALL work including finished details. APPROVAL to
operate shall not be granted, or remodeled areas approved to operate, until the facility has passed the FINAL
INSPECTION, and "APPLICATION TO OPERATE" has been completed and PERMIT FEES have been paid.
Request for inspection should be made at least five(5)working days in advance.
PLANS CHECKED BY Jeff Lojeski, REHS Phone 951-766-2824
I acknowledge the corrections noted erein and as indicated on the plans and agre to in rporate them during
construction:
Signature Date4o
Company Name
:)EH-SAN-178(Rev 2/161
Corona Hemet Indio Murrieta Palm Springs Riverside-west Riverside-east
75 S.brain St#204 $00 S.Sanderson#200 47.95o Arabia&"A" 38740 Sky Canyon Dr. 544 S.Pasco Dororea 4065 County Cimle 3880 Lemon St
:orona,Ca 92882 Hemet,Ca 92545 Indio,Ca 92201 Murrieta,Ca 92563 Palm Springs,Ca Riverside,Ca 92103 Riverside,Ca 92501
(951)273,9140 (951)76&2824 (760)863-8287 (951)461-0284 92264 (951)358.5172 (951)955,8982
x(951)520.8319 Fax(951)766-7874 Fax(760)8634303 Fax(951)461-0245 (760)320-1048 Fax(951)35&5017 (951)955.8988
Fax(760)320,1470
Department Web Site-www.rivcoeh.org
�Me1L�
sA County of Riverside
DEPARTMENT OF ENVIRONMENTAL HEALTH
µF ywt FOOD ESTABLISHMENT PLAN APPROVAL NOTICE
Service Request# 41450 Date 5/1/18
Project Name Cafd Rio Address 29881 Antelope Road, #4A, Menifee, CA
Plans Submitted by Matt Clark Phone 714-928-1166
Owner SAA Address SAA Phone SAA
The plans are now approved subject to the conditions listed below and the attached compliance sheet.
1) Provide will serve and grease interceptor waiver/clearance letters at time of plan pick-up.
2) Provide an air balance report, for all Type I exhaust hoods, at time of final inspection.
CONSTRUCTION INSPECTIONS: Contact the Plan Checker for a Preliminary Inspection when construction is
approximately 80% complete, with plumbing, rough ventilation, and rough equipment installed. Request for
inspection should be made at least five (5) working days in advance.
A FINAL INSPECTION MUST be made upon completion of ALL work including finished details. APPROVAL to
operate shall not be granted, or remodeled areas approved to operate, until the facility has passed the FINAL
INSPECTION, and "APPLICATION TO OPERATE" has been completed and PERMIT FEES have been paid.
Request for inspection should be made at least five (5)working days in advance.
PLANS CHECKED BY Jeff Lojeski, REHS Phone 951-766-2824
1 acknowledge the corrections noted herein and as indicated on the plans and agree to incorporate them during
construction:
Signature Date
Company Name
DEH-SAN-178(Rev 2/16)
Corona Hemet Indio Murrieta Palm Springs Riverside-west Riverside-East
2275 S.Main St#204 800 S.Sanderson#200 47-950 Arabia St"A" 38740 Sky Canyon Dr. 544 S.Pasco Donates 4065 County Circle 3880 Lemon St.
Corona,Ca 92882 Hemet,Ca 92545 Indio,Ca 92201 Murrieta,Ca 92563 Palm Springs,Ca Riverside,Ca 92503 Riverside,Ca 92501
(951)273-9140 (951)766-2824 (760)863-8287 (951)461-0284 92264 (951)358.5172 (951)955.8982
Fax(951)520-8319 Fax(931)766-7874 Fm(760)863.8303 Fax(951)461.0245 (760)320-1048 Fax(931)358.3017 (951)955-8988
Fax(760)320-1470
Department Web Site-www,rivcoeh.org
�C
E L L I S
CONTRACTING. INC.
September 4, 2018
City of Menifee
Building and Safety Department
29714 Haun Road
Menifee, CA 92586
To Whom It May Concern:
Ellis Contracting, Inc. hereby authorizes Buddy Lockhart to sign on our behalf and pull a
permit for Caf6 Rio Mexican Grill Tenant Improvement located 29881 Antelope Road,
Suite 4A, Menifee, CA 92854
Our Workmen's Compensation 907734217 expires 11/1/2018 l--�
California State Contractor's license number is 785647. 1--�
If you have any questions, please contact John Ellis at (619) 922-6246
Sincerely,
Erin M. Ellis
Vice President
401 O MORENA BLVD. SUITE 21 O • 5AN DIEGO. CA 921 1 7 • TEL 858.581.1 16O • FAx 858.581.1 165 • LIc. #785647
Client#: 1253804 303ELUSCON
ACORD. CERTIFICATE OF LIABILITY INSURANCE D101302017ATE V
1 0/3 012 01 7
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed.If SUBROGATION 18 WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER NpNTACT Sherlisse Yehiing
BB&TJohn Burnham Ins Services PxoxE 619 231.1010 tiro Na; 6192369134
C No Exl
750 B Street Suite 2400 E-MAIL
ADDRESS:
San Diego,CA 92101 INSURER(S)AFFORDING COVERAGE NAIC4
619 231.1010 INSURER A:Mt. Hawley Insurance Company 37974
INSURED INSURER B,Great American Alliance Insuran 26832
Ellis Contracting Inc. I INSURER C:State Compensation Ins.Fund of 35076
4010 Morena Blvd.#210 INSURER D:
San Diego,CA 92117 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OFINSURANCE I gRL UpR POLICY NUMBER MMMD/YEFF YYy MMIDDYE� LIMITS
LTR
A X COMMERCIAL GENERALUABILIW MGL0188278 1110112017111011291 EACH OCCURRENCE S1 O00000
CLAIMS-MADE �OCCUR PRE ��
ES Eaaxc.rD $50 ODO
MEO EX?(Any one arson $5000
PERSONAL&ADV INJURY $1,000000
GEN'LAGGREGATE UMITAPPUES PER: GENERAL AGGREGATE $2000000
JEC
POLICY a PRO- LOC PRODUCTS-COMP/OP AGO s2,000,000
S
OTHER
COMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY Ee eccitle 1
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS PROPERTY DAhNGE
NON_OWNED $
Per ecWdeW
HIRED AUTOS AUTOS $
B UMBRELLA LIAR X OCCUR UMB2063658 1101/2017 11/0i/201F EACH OCCURRENCE $5 00O 000
X EXCESS LIAR CLAIMS-MADE AGGREGATE s5 00g 0D0
OED I X RETENTION 1O 000 $
G WORKERS COMPENSATION 907734217 1110112017 11101/201E X PER EE
AND EMPLOYERS'LIASIUTY
ANY PROPRIETORIPARmEWEXECUTIVEYIN E.L.EACH ACCIDENT $100000D
OFFICER/MEMBER EXCLUDED? ❑[NI
(Mandalmy in NFq E.L.DISEASE-EA EMPLOYEE $1 00O 000
If yea,deecdbe under E.L.DISEASE-POLICY LIMIT $1000000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Addidonal Remarks Schedule,may be attached It more space Ia mgWmd)
Certificate is subject to policy limits,conditions and exclusions.
This Certificate has been issued as evidence of insurance Coverage only
and is not to be reproduced.
CERTIFICATE HOLDER CANCELLATION
City of San Diego, Mall Station SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
31 ACCORDANCE WITH THE POLICY PROVISIONS,
122.2 First Avenue
San Diego,CA 92101 AUTHORIZED REPRESENTATIVE
. ..d; —
e 1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014101) 1 Of 1 The ACORD name and logo are registered marks of ACORD
#S7 89755 8 81M18974737 MGGUE
i
CONTRAC70RS
ww w� p STAACTIVE LICE S BOARD
��.. � 786647
ELLIS CO " CORP
NTRACTING INC
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a. 10/31/2018 �9
www.cslb.ra.gov �i►z.4