PMT18-02295 City of Menifee Permit No.: PMT18-02295
29714 HAUN RD. Type: Pool/Spa-Residential
�-!S\CCEL/� MENIFEE,CA 92586
MENIFEE Date Issued: 05/1012018
PERMIT
Site Address: 28933 PARK TRAIL WAY,MENIFEE,CA Parcel Number: 333-650-008 _
92584 Construction Cost: $20,000.00
Existing Use: Proposed Use:
Description of 512 SO FT POOL AND SPA WITH 2 LIGHTS.14.5'BY 50'SOLID ALUMAWOOD PATIO COVER WITH
Work: 3 LIGHTS.UG GAS LINE TO FUTURE BBQ PIT
Owner Contractor
HARRY&GLADYS JACOBSEN ,
28933 PARK TRAIL WAY
MENIFEE,CA 92584
Applicant License Number:
HARRY&GLADYS JACOBSEN
28933 PARK TRAIL WAY
MENIFEE,CA 92584
Phone:9512591782
Fee Description p yty Amount(S)
Receptacle,Switch, Outlet&Fixture 3 126:00
Swimming Pool/In-Ground Spa 1 467.00
Plumbing Fixtures and Vents,fixtures 1 116.00
Building Permit Issuance 1 27.00
Deck/Patio, non-standard 1 133.00
GREEN FEE 1 1.00
SMIP RESIDENTIAL 1 _ 3.00
General Plan Maintenance Fee-Building 1 6.65
General Plan Maintenance Fee-Plumbing 1 5.80
General Plan Maintenance Fee-Electrical 1 29.65
$915.10
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
with a licensed contractors)pursuant to the Contractors State License Law).
1 hereby affirm under penalty of perjury that I am under provisions of �' �,tt�
Chapter9(commencing with section 7000)of Division 3 of the Business and /7s-am exempt from licensure under the ContrectPr_T_Itate License Law for
Professions Code and my license is in full force and effect. Y the fallowing reason: r {,vi L<'1 P v
License Class License No. By my signature below I acknowledge that,except form g p y 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
` 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 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 www.IeFinfo.ca.gov/caIaw-htmI.permit is issued.
Policy# 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 D By my signature below I certify to each of the following:)am the property
this permit is issued.My workers compensation insurance carrier and policy owner or authorized to act on the property owners beha If.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 Date
dollars($100)or less PROPERTY OWNER OR AUTHORIZED AGENT
D 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 If
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 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 specified on the Hazardous Materials Information Guide?
WARNING:FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE LS ❑Yes Alo
UNLAWFUL,AND SHALLSUBIECTAN EMPLOYERTO 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(SC construction
or See permitting checklist
IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES forCoast
Airlines
Qua
CONSTRUCTION LENDING AGENCY 0Yes 040
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
1EA
ealth&Safety Cade,Section 25505 and 25534 concerning
Contractors License Law for the reason(s)indicated below by the materialreprtingcheckmark(s)I have placed next to the applicable Rem(s)(Section 7031.5 Narr-�'Business and Professions Code).Any city or county that requires a permit to Date 7'1construct,alter,Improve,demolish or repair any structure,prior to its 0 N OR A HORIZED AGENTissuance,also requires the applicant for the permit to file a signed statementthat he or she is licensed pursuant to the provisions of the Contractors State OVATIO REPA AND PAINTING RRP
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
❑1,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( I portion of the work,and the structure is svww.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).
Cade;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.
BUILDING & SAFETY PERMIT/PLAN CHECK APPLICATION MENIFEE
DATE: D PERMIT/PLAN CHECK NUMBER
PLANNING CASE NUMBER
TYPE: O COMMERCIAL ESIDENTIAL O MULTI-FAMILY O MOBILE HOME O POOL/SPA O SIGN
SUBTYPE: O ADDITION O ALTERATION O DEMOLITION O ELECTRICAL O MECHANICAL
O NEW O PLUMBING O RE-ROOF NUMBER OF SQUARES
-
I
� p DESCRIPTION OF WORK P60L A n d�_ S a_ .S t./ 470 S
VII01 2 /7QC� (�(
(J PROJECTADDRESS G (j ka' r/�( ZIP l 2s
ASSESSOR'S PARCEL NUMBER LOT TRACT
OWNER NAME qqk 3 GICI &AS 0_c_
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ADDRESS ��b '7j 3J Pa-r k= r-OL. W f4 cv lI �
PHONE - 1�^ p`7 T?11Z EMAIL CAM
APPLICANT NAME
g v' S +(� Q
ADDRESS O9 �' cLrk_7[ " 1 G, M�y1Y .e-e_
PHONE '3S 2S / Z EMAIL
CONTRACTOR'S NAME OWNER BUILDER? ,d'ES ONO
BUSINESS NAME
ADDRESS
PHONE EMAIL
CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION
0
VALUATION$ SQSQ FT M, L SQ FT/'�//� / ^x
APPLICANT'S SIGNATURE o -{ ��GI/ DATE "'� ` �I �' U
DEPARTMENT DISTRIBUTION ACCEPTED BY: CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE ,
INVOICETOTAL �01 GREEN SMIP
OWNER BUILDER VERIFIED OYES O NO DRIVERS LICENSE# NOTARIZED LETTER O YES O NO
City of Menifee Building &Safety Department 129714 Haun Rd., Menifee, CA 92586 (951)672-6777
www.cityofinenifee.us CIty Of enwee
Building De0t• NIF
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CITY OF MENIFESAFETY DEPARTMENT
" BUILDING AND
'Arc i PLAN APPROVAL
REVIEWED BY DA
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vaI oI these plans shag riot be constnred to tie a pe�ft�'°f M
Appro i
approval of,any violators of any provisrons of � �
regulations and ordinances•ibis set 01 Wm"d PW*
iobsite until completion-