PMT18-03743 City of Menifee Permit No.: PMT18-03743
29714 HAUN RD.
MENIFEE, CA 92586 Type: Residential Alteration
MENIFEE MENIFEE Date Issued: 07/31/2018
PERMIT
Site Address: 29687 AVENDIA DE SERENO, MENIFEE, Parcel Number: 336-221-006
CA 92586 construction Cost: $5,000.00
Existing Use: 1 &2 Family Residence Proposed Use:
Description of MINOR BATHROOM REMODEL, REPLACE EXISTING SHOWER WITH NEW WALK-IN SHOWER,
Work: RELOCATE DRAIN AND SHOWER VALVE LOCATION, 1 NEW GFCI OUTLET, DRYWALL PATCH
WORK
Owner Contractor
JEFFREY CARTER SUPER BUILDERS
29687 AVENIDA DE SERENO 23068 SKYLINK
MENIFEE, CA 92586 CANYON LAKE, CA 92587
Applicant Phone:9512590079
RAZ GRINBAUM License Number: 334090
SUPER BUILDERS
23068 SKYLINK
CANYON LAKE, CA 92587
Fee Description Q1t r Amount ISl
Receptacle, Switch,Outlet.&Fixture 1 116.00
Plumbing Fixtures and Vents,fixtures 2 116.00
Building Permit Issuance 1 27.00
GREEN FEE 1 1.00
General Plan Maintenance Fee-Plumbing 1 5.80
General Plan Maintenance Fee-Electrical 1 5.80
$271.60
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 caned 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
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 force and effect. the following reason:
License C ss License No. h By my signature below I acknowledge that,except for my personal residence
Expire 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 DECLA
have built as an owner-builder if it has not been constructed in its entirety by
a 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 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
www leainfo ca Rov/calaw.h[ml.
this permit is issued.
Policy# Date
sMhave and will maintain workers compensation Insurance,as required by PROPERTY OWNER OR AUTHORIZED AGENT
wn 3700 of the Labor Code,for the performance of the work for which O 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 an the property owners behalf.I have read this
number are: application and the Information I have provided is correct.I agree to comply
with all applicable city and county ordinances and state laws relating to
Carrier building construction.I authorize representatives of this city or county to
Policy# 01 �'��G+9 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
❑I certify that in the performance of the k for which this permit is Issued,
I shall not emolov any persons in an ner so as to become subject to the CITY BUSINESS UCENSE#
workers compensation laws of do ia,and agree that if I should become HAZARDOUS MATERIAL DECLARATION
subject to the workers co ensati provisions of Section 37DO QQQf the Labor
Code,I shall forthwith mply wi those provisions. Will the applicant or future building occupant handle hazardous material Ora
Applicant Date 1 DJT ` mixture containing a hazardous material equal to or greater that the
amounts specified on the Hazardous Materials Information Guide?
WARNING. URETO SEC RE WORKER'S COMPENSATION COVERAGE IS ❑yes )WO
UNLAWFUL,AND SHALL S PLOYER 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 )%No
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 �Qo
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
California Health al Safety Code,Secti 5505 and 213M4 eContractors License Lawfor the reasons)indicated below by the iazardoas material reporting. rring
checkmark(s)I have placed next to the applicable item(s)(Section 7031.5 es ❑No 1Businessand Professions Code).Any city or county that requires a permitto Date 1
construct,alter,improve,demolish or repair any structure,prior to its PROPERTY NER 0 U7 GENT
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 RE 10 PAIR 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
D 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( )portion of the work,and the structure is www.eO La�g_ov/lead/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:
o 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: ! \ % PERMIT/PLAN CHECK NUMBER emeb-w�n4
PLANNING CASE NUMBER
TYPE: O COMMERCIAL 4 RESIDENTIAL O MULTI-FAMILY O MOBILE HOME O POOL/SPA O SIGN
SUBTYPE: O ADDITION O ALTERATION O DEMOLITION A ELECTRICAL O MECHANICAL
O NEW 'StPLUMBING O RE-ROOF NUMBER OF SQUARES
DESCRIPTION OF WORK ✓tvY K�c�e
\-\ -'N� e %O �e
PROJECTADDRESS 2--C168-j N\J ZIP �L2S�60.
ASSESSOR'S PARCEL NUMBER 3 1' CCtq LOT TRACT
OWNER NAME City of Menifee
ADDRESS Building ep .
JUL
PHONE EMAIL 3 1
APPLICANT NAME
ADDRESS LAY,, ^ \_ NV'_ Q
PHONE &1b- WAS \aBS EMAIL � Yl.. '(gyp �•.�GC, N
CONTRACTOR'S NAME OWNER BUILDER? O YES ' NO
BUSINESSNAME —lt'�.�'1 C-(-o"- C �
ADDRESS
PHONE C�c\ ,2��1r o- EMAIL
CONTRACTOR'S STATE LIC NUMBER a;bLtO`l D LICENSE CLASSIFICATION
VALUATION$ rj,pp;Z> SQ FT L SO FT
APPLICANT'S SIGNATURE DATE
CITYSTAFF USE ONLY
DEPARTMENT DISTRIBUTION ACCEPTED BY: CITYOF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE
INVOICETOTAL 0•U10 GREEN SMIP 1,�
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
iWNW67,
City of Menifee
Building Dept.
"i
JUL 3 1 2018
Received
i
t
in
n
>7�r
c
CITY OF MENIFEE
BUILDING AND SAFETY DEPARTMENT
PLAN APPROVAL
REVIEWED BY—LLW—A�7;k Q
DATE
•Approval of these plans shall not be construed to be a permit for,or an
approoa!af,any violation of any provisions of the federal,state or city
regulations and ordinances. This set of approved plans must be kept on the
jobsite until completion.
City of Menifee
Building Dept.
JUL 3 1 2018
SUPER Builders
7467 Crawford Place y
Rancho Cucamonga,CA 91739 Received
License#334090
v
�n
Letter of Authorization
I,Ernest Ybarra, Owner of Super Builders, license#334090 hereby authorize Raz
Grinbaum and Dor Levi of RG Permits and Design Services,as my agents for the
purpose of obtaining a building permits,business licenses, and to sign on any document
in my name, as necessary,for conducting business in your city.
Respectfully,
Ernest Ybarra
Super Builders i7x—
D�\ Lb C\b
M.T. GARCIA
COMM.#2072225 InV.?- :.� Notary Public-California r'i
SAN BERNARDINO COIJNttA
texa My Comm.Exp.Jul.19, 2014
CALIFORNIA JURAT WITH AFFIANT STATEMENT GOVERNMENT CODE g 8202
*See Attached Document(Notary to cross out lines 1-6 below)
❑See Statement Below(Lines 1-6 to be completed only by document signerls], not Notary)
Sig/fr ure of Document Signer No. 1 Signature of Document Signer No.2(if any)
Fnwotary public or other officer completing this certificate verifies only the identity of the individual who signed the document
hich this certificate is attached,and not the truthfulness,accuracy,or validity of that document.
State of California 0n Subscribed and sworn to (or affirmed) before m�e�
County of � �r na Y�C i YI _ on this�r ed day of 5� 20 c rt
,
by Date i/ nth Year
(1) -E�7ymp'C� 11�GCY1rCc
(and(2)
M.T. GARCIA ti
Nome(s)of Signers)
G COMM.#2072225
i-' ` s .,.,j-ry Nota, Public v y proved to me on t e basis of satisfactory evidence to
8AN BERNARDMO COUNTYA
My Comm.Exp.Jul.19,2018 be the persons who app ar d before me.
Signature
Place Notary Seal and/or Stamp Above Signature of Notary Public
OPTIONAL
Completing this information can deter alteration f the document or
fraudulent reattachment of this form to an uninte ed document.
Description of Attached Document /! y�
Title or Type of Document: -'' F'_`! _ UT- AJj:h0Y'J 7 jp4L 0 YI
Document Date: G. OV-5� 20 17 Number of Pages:
Signer(s)Other Than Named Above:
02017 National Notary Association