PMT18-03286 City of Menifee Permit No.: PMT18-03286
29714 HAUN RD.
�1 MENIFEE, CA 92586 Type: Residential Re-Roof
MENIFEE MENIFEE Date Issued: 07/02/2018
PERMIT
Site Address: 27550 GROSSE POINT DR, MENIFEE, Parcel Number: 335-241-015
CA 92586 Construction Cost: $9,000.00
Existing Use: Proposed Use:
Description of TEAR OFF EXISTING, REPLACE W/CERTAINTEED SOLARIS RE-SAWN SHAKE COOL ROOF
Work: CRRC#0668-0118
Owner Contractor
JANE SIMMONS HOUSETOP ROOFING
27550 GROSSE POINT DR 31760 BRIGGS ROAD
MENIFEE, CA 92586 MENIFEE, CA 92584
Applicant Phone:9516798369
RICH CARROLL License Number:371783
HOUSETOP ROOFING
31760 BRIGGS ROAD
MENIFEE, CA 92584
Fee Description ON Amount f$1
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
CIiY OF MENIFEE
LICENSED DECLARATION property who builds or improves thereon,and who contracts far the projects
1 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 o I am exempt from Iicensure under the Contractor's State License Law for
Professions Code and my license is in full force and effect. the following reason:
Ucense Class C `3�_License No. �7I�/�O By my signature below I acknowledge that,except for my personal residence
Expires Signature jfZ in which l 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 DECLARATI 1 have built as an owner-builder if it has not been constructed in its entirety by
o l 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 for which
this permit is issued. www.leeinfo.ca.eov/calaw.html.
Policy# Date
dove 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 l 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 behalf.I have read this
number are: application and the information I have provided is correct.I agree to comply
Carrier (/1U� with all applicable city and county ordinances and state laws relating to
building construction.I authorize representatives of this city or county to
Policy# ��!'oe2 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($IOD)or less PROPERTY OWNER OR AUTHORIZED AGENT
,%�-.rtlfythat in the performance of the work for which this permit is issued, 2 (�
I shall not employ any persons in any manner so as to become subject to the CITY BUSINESS LICENSE# o3b5�'I
workers compensation laws of California,and agree that if I should become HAZARDOUS MATERIAL DECLARATION
subject to the workers compensation provisions of Section 370D of the Labor
Code,I shall forthwith comply with those provisi s. Will the applicant or future building occupant handle hazardous material or
Applicant Date 2. Z� mixture containing a hazardous material equal to or greater that the
amounts specified on the Hazardous Materials Information Guide?
WARNING:F4LURE TO SECURE WORKER'S COMPENSATION COVERAGE IS OYesK.
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($100,000),IN occupant requires permit for the construction or modification from South
IN SECTION ON TO
06 OF
LABOR CODE,INTERTION,DAMAGESDATTOR ATTORVIDEDNEYS
FOR Coast Air Quality Management District(SCAQMD)?See permitting checklist
IN SECTION 3706 OF THE LABOR CODE,INTEREST,ANDA7TORNEYS FEES forgutdelin
CONSTRUCTION LENDING AGENCY oyes Al..a
I hereby affirm that under the penalty of perjury there is a construction Will the proposed building or modified facility be within 1000 feet of the
lending agency for the performance of the work which this permit is issued outer boundary of a school?
(Section 3097 Civil Code) aYes 9K.
OWNER BUILDER DECLARATIONS I have read the Hazardous Material Information Guide and the SCAQMD
I hereby affirm under penalty of perfurythat l am exempt from the permitting checklist.I understand my requirements under the State of
Contractors License Law for the reason(s)indicated below by the California Health&Safety Code,Section 25505 and 25534 concerning
checkmark(s)I have placed next to the applicable item hazardous material reporting.$)(Section 7031.5 oyes
Business and Professions Code).Any city or county that requires a permit to Date Z�
construct,alter,improve,demolish or repair any structure,prior,to its pROPEg WNER OR AUTHORIZED AGENT
issuance,also requires the applicant forthe permit to file a signed statement
that he or she Is licensed pursuant to the provisions of the Contractors State EPA RE OVATION.REPAIR AND PAINTING IRRP)
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)orthat he or she is exempt from Iicensure receiving compensation for most work that disturbs paNtinapre•1978
andApplim the basis fora Peallegedects th applicn.Anyant
nto oaci of Section of not o residence or childcare facility to be RRP-certified firms and comply with
than
Applicant fora permit subjects the applicant too civil penalty of not more required practices.This includes rental property owners and property
than{$500). managers who do the paint-disturbtng work themselves or through their
O1,as owner of the property,or my employee with wages as their sale 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.epa.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 ciAn 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. D No EPA Lead-Safe Certified Firm is required for this project because:
O I,as owner of the property am exclusively contracting with licensed
contractors to construct the project(Section 70",Business and Professions
Code: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.
APPLICATIONBUILDING & SAFETY PERMIT/PLAN CHECK
Menifee
DATE: 7 /Y/ PERMIT/PLAN CHECK NUMBER
TYPE: O COMMERCIAL k RESIDENTIAL O MULTI-FAMILY O MOBILE HOME O POOL/SPA O SIGN
SUBTYPE: O ADDITION O ALTERATION O DEMOLITION O ELECTRICAL O MECHANICAL
ONEW OPLUMBING �'RE-ROOF NUMBER OF SQUARES
DESCRIPTION OF WORK lZeV&44eg- Ld/7;V-
oc Sa6A70s 4&-5AVA1 S .4� Cod(-
PROJECTADDRESS oq25 -6 6led556 ZIP �
ASSESSOR'S PARCEL NUMBER ��Jl o2�'�J-Q(rj LOT cQO TRACT ` 1 4
OWNER NAME7W
ADDRESS
PHONE (O 7Y- EMAIL
APPLICANT NAME Z/C/v- C' x1faeC�
ADDRESS ,3/ /t/ �.
PHONE (ads-/7// EMAIL ?/o7/.�/L. C0/1"
CONTRACTOR'S NAME x/ OWNER BUILDER? O YES O NO
BUSINESS NAME /v 2rok ,I, /
ADDRESS Y-Q.
PHONE (),�/7// EMAIL 6E�, 4'rjo' vin, • 1�9/"
CONTRACTOR'S STATE LIC NUMBER 2-21 V 3 LICENSECLASSIFICATION
VALUATION$ ,, OD SQ FT Z � O L SO FT
APPLICANT'S SIGNATURE DATE
STAFF USE ONLY _
DEPARTMENT DISTRIBUTION CITY OF MENIFEE BUSINESS 11CIENSE NUMBER
BUILDING PLANNING ENGINEERING FIR I
ACCEPTED BY: O
PERMIT FEE • U SMIP GREEN
PLAN CHECK FEE INVOICE TOTAL
OWNER BUILDER VERIFIED O YES O NO DRIVERS LICENSE# NOTARIZED LETTER O YES O NO
City of Menifee Building&Safety Department 29714 Houn Rd. Menifee, CA 92586 951-672-6777
www.Cityofinenifee.us
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