PMT18-03583 City of Menifee Permit No.: PMT18-03583
29714 HAUN RD.
I Type: Residential Re-Roof
1 MENIFEE,CA 92586
MENIFEE MENIFEE Date Issued: 07/18/2018
PERMIT
Site Address: 29677 PARKCITY AVE, MENIFEE,CA Parcel Number: 339-223-016
92584 Construction Cost: $14,000.00
Existing Use: Proposed Use:
Description of TEAR OFF EXISTING SHINGLES 2400SF, REROOF CRRC#1214-0005, IKO CAMBRIDGE COOL
Work: SERIES VALLEY OAK
Owner Contractor
BARTON HANEY JAX J C C INC
29677 PARK CITY AVE 1270 COLUMBIA AVE STE F8
MENIFEE,CA 92584 RIVERSIDE,CA 92507
Applicant Phone:8332677663
JAX J C C INC License Number:992388
1270 COLUMBIA AVE STE F8
RIVERSIDE,CA 92507
Fee Description ON Amount($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.rpl 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 with a 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 Contractor's State License Law for
Professions Code and my license is in full farce and effect. the following reason:
License Class License No. Iq 23!gfl By my signature below I acknowledge that,except for my personal residence
Expires Signature�.l.(-���S 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
,ZI 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.leginfo.ca.gov/calaw.htmi.
this permit is issued.
Policy#14� Date
y 1,have and will maintain worker's compensation insurance,as required by PROPERTY OWNER OR AUTHORIZED AGENT
section 3700 of the Labor Cade,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 SS'tATf �tT,vu.^�AJS .Tro,v �vLa� with all applicable city and county ordinances and state laws relating to
1 building construction.I authorize representatives of this city or county to
Policy# �12)I Soo) Expires G— 2— 19 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
AJ certify that in the performance of the work for which this permit is issued,
'I shall not employ any persons in any manner so as to become subject to the CITY BUSINESS LICENSE#
worker's compensation laws of California,and agree that if I should become HAZARDOUS MATERIAL DECLARATION
subject to the worker's compensation provisions of Section 3700 of the Labor
Code,I shall fo (:wit amply with those provisions. C, will the applicant or future building occupant handle hazardous material or a
Applicant II Date -7— O 9 mixture containing a hazardous material equal to or greaterthat the
amounts specified on the Hazardous Materials Information Guide?
WARNING:FAILUR TO SE URE WORKER'S COMPENSATION COVERAGE IS ❑Yes Po
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 forguidelines
CONSTRUCTION LENDING AGENCY ❑Yes No
I hereby affirm that under the penalty of perjury there is a construction WIII 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
permitting checklist.I understand my requirements under the State of
I hereby affirm under penalty of perjurythat I am exempt from the
Contractor's License Law for the reason(s)indicated below by the California Health&Safety Code,Section 25505 and 25534 concerning
hazardous material reporting.
checkmark(s)I have placed nett to the applicable Item(s)(Section 7031.5 Y..L,�� !;
Business and Professions Code).Any city or county that requires a permit to oyes H.
� (I/I �A` ' Date ��
construct,alter,improve,demolish or repair any structure,priorto its PROPERTY O17WNER R AU I ORI D 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 Contractor's State EPA RENOVATION,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 Cade)or that he or she is exempt from licensure receiving compensation far 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( )all of or( )portion of the work,and the structure is www.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).
Code;The Contractor's 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 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.
BUILDING & SAFETY PERMIT/PLAN CHECK APPLICATION MENIFEE
DATE: 7 PERMIT/PLAN CHECK NUMBER
GRADING/ PLANNING CASE NUMBER/OTHER RELATED CASES
TYPE: O COMMERCIAL ARESIDENTIAL O MULTI-FAMILY O MOBILE HOME O POOL/SPA O SIGN
SUBTYPE: O ADDITION O ALTERATION O DEMOLITION O ELECTRICAL O MECHANICAL
ONEW O/PLUMBING XRE-ROOF NUMBER OF SQUARES 2Z1
DESCRIPTION OF WORK /� �� 5)r! i G
OCCUPANCY GROUP Q I n CONSTR<)CTION TYPE SPRINKLERS O YES ANO
PROJECT ADDRESS 0%?-7JAKh��L'y,•, 'ny'L- ^/2bE.ti'iFcL�C IF zipCity ZSS
ASSESSOR'S PARCEL NUMBER 3�jCt` �iZ� 6—Q16COT TRACT BuilofMenefee
OWNER NAME 7bjh�,M_ eJ E
ADDRESS Z -7 r-k Cj t' E1V/ 2�5— CA
PHONE qoq -S18 - 54j& EMAIL j S G/vvP ceived
APPLICANT NAME
ADDRESS
PHONE EMAIL
CONTRACTOR'S NAME r ' ..IonJE.S OWNER BUILDER? OYES CANO
BUSINESS NAME _,4 0 C.0 ,.Jc . RA -
ADDRESS Z( LU r%a AL/C. I Ca. -s 9 2�
PHONE J01 L{-j EMAIL j-3 pM $off 6'I ..'sr Ca/JST�uCT�e�
CONTRACTOR'S STATE LIC NUMBER LICENSE CLASSIFICATION
VALUATION$ Jrf/066'6b SOFT 2-gDO LSQFT O
APPLICANT'S SIGNATURE . - DATE g 0
DEPARTMENT DISTRIBUTION ACCEPTED BY: ry ,�` CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE
INVOICETOTAL 1 2,0, O' GREEN 1 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.cityofmenifee.us
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To whom it may concern,
Billy Thompson as an agent of Jax J CC Inc. dba
AMS construction has my permission to
conduct business on my behalf.
Signed
�E2�kMiE �}Or��S
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 CalifomiR
County of L .b,kA-PLbs ( Q, ) (�
On Jx q ��� before me, CSC c� L U�OTa �+�i �1 JOIi
(insert narn nd title of the officer)
personally appeared 4 -e-, '`,c)r'Q S
who proved to me on the basis of satisfactory evidence to be the person(p)whose name(O is/ape
subscribed to the within instrument and acknowledged to me that he/sire/grey executed the same in
his/tjer/tt}eir authorized capacity(ips),and that by his/h,or/Weir signature(%%)on the instrument the
person(), or the entity upon behalf of which the person(s)acted, 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.
STACky_POLK
WITNESS my hand and official seal. ComrMnioo r 2133M
Notary POWIc•Ctll im@
Skn.9anardino County_. -
M Comm.Ei hl Nor 13.2019
Signature (Seal)
_ � -ORIV.ERlI �SE
LN
q �� FN.JE END NONE
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