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PMT18-03714 City of Menifee Permit No.: PMT18-03714 29714 HAUN RD. Type: Residential Electrical IIAF MENIFEE, CA92586 MENIFEE MENIFEE Date Issued: 08/17/2018 PERMIT site Address: 26843 GARBANI RD, MENIFEE, CA Parcel Number: 360-200-006 92584 Construction Cost: $2,000.00 Existing Use: Proposed Use: Description of UPGRADE SERVICE PANEL TO 225A/200A MAIN CIRCUIT BREAKER. Work: Owner Contractor KENNETH STILES BOERSMA CONSTRUCTION CORPORATION 26843 GARBANI RD 5433 BRODERICK COURT MENIFEE, CA 92584 HEMET, CA 92544 Applicant Phone:9515708706 BOERSMA CONSTRUCTION CORPORATION License Number: 994778 5433 BRODERICK COURT HEMET, CA 92544 Fee Description ON Amount 1$) Services, Switchboards,Control Centers&Panels 1 116.00 Building Permit Issuance 1 27.00 GREEN FEE 1 1.00 General Plan Maintenance Fee-Electrical 1 5.80 $149.80 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 forthe projects I hereby affirm under penalty of perjurythat 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 Contractors State License Law for Professions Code and my license is in full force and effect. the following reason: License Class L— 10 License No. 7 By my signature below 1 acknowledge that,except for my personal residence Expires-7 r/3 12x���signatu ep u 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 ❑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 Cade,for the performance of work for which www.leginfo.ca.aov/calaw.html. this 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 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: 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 iden 'feredproperty fo in ection purposes. (This section need notto be completed is the permit is for one-hundred V014 Date 8 p dollars( 100)or less P O ERTYOWNE RAHTHO IZEDAGENT erdfy 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# 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 wi -those provisi ns. Will the applicant or future building occupant handle hazardous material or a Applicant4 � ate mixture containing a hazardous material equal to or greater that the 1 amounts soe ed on the Hazardous Materials Information Guide? WARNING:FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE 15 ❑Yes b 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, CONSTRUCTION LENDING AGENCY ❑Yes dq�o 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 V. OWNER BUILDER DECLARATIONS I have read the Hazardous Material Information Guide and the SCAQMD permitting checklist.I understand my requirements underthe State of I hereby affirm under penalty of perjury that I am exempt from the California Health Contractor hazardous matteeria Safety Cade,Section 25505 and 25534 concerning s License Law for the reason(s)indicated below by the a checkmark(s)I have placed next to the applicable item(s)(Section 7031.S l repo g. mYe� ❑No �//'O Business and Professions Code).Any city or county that requires a permit to Fl.;Q 44h.Ad/g ^ate d? I J construct,alter,improve,demolish or repair any structure,prior to its PROPERTY OWNER 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 RENOVATION,REPAIR AND PAINTING fRRPI 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 orthrough 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 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. :heck A License - License Detail Page 1 of Contractor's License Detail for License # 994778 DISCLAIMER:A license status check provides information taken from the CSLB license database. Before relying on this information,you should be aware of the following limitations. CSLB complaint disclosure is restricted by law(B&P 7124.6)If this entity is subject to public complaint disclosure,a link for complaint disclosure will appear below.Click on the link or button to obtain complaint and/or legal action information. Per B&P 7071.17,only construction related civil judgments reported to the CSLB are disclosed. Arbitrations are not listed unless the contractor fails to comply with the terms of the arbitration. Due to workload,there may be relevant information that has not yet been entered onto the Board's license database. Business Information BOERSMA CONSTRUCTION CORPORATION dba WEST COAST GREEN ELECTRIC 5433 BRODERICK COURT HEMET,CA 92544 Business Phone Number:(951)570-8706 Entity Corporation Issue Date 07/18/2014 Expire Date 07/31/2020 License Status his license is current and active. II information below should be reviewed. Classifications _n 10-ELECTRICAL Bonding Information • Contractor's Bond This license filed a Contractor's Bond with WESTERN SURETY COMPANY. Bond Number: 63596955 Bond Amount: $15,000 Effective Date: 04/05/2018 Contractor's Bond History Bond of Qualifying Individual The qualifying individual SAM BOERSMA III certified that he/she owns 10 percent or more of the voting stock/membership interest �} f this company;therefore,the Bond of Qualifying Individual is not required. Effective Date:07/18/2014 Workers'Compensation his license is exempt from having workers compensation insurance;they certified that they have no employees at this time. Effective Date: 0 612 5/2 01 8 xpire Date: None r/Jorkers'Compensation History ittps://www2.cslb.ca.gov/OnlineServi... Check A License -License Detail 8/17/2011