PMT18-04067 City of Menifee Permit No.: PMT18-04067
29714 HAUN RD.
MENIFEE, CA 92586 Type: Residential Demolition
MENIFEE MENIFEE Date Issued: 08/16/2018
PERMIT
Site Address: 27781 SCOTT RD, MENIFEE, CA 92584 Parcel Number: 384-180-002
Construction Cost: $2,000.00
Existing Use: Proposed Use:
Description of DEMO EXISTING GARAGE,900 SF,AND SINGLE FAMILY RESIDENCE,980 SF
Work:
Owner Contractor
DEANNA LAWRENCE HERMANOS GRADING INC
27781 SCOTT ROAD 17811 SLOVER AVENUE
MENIFEE, CA 92584 BLOOMINGTON, CA 92316
Applicant Phone:9098731453
CARLOS MADRIGAL License Number:795209
HERMANOS GRADING INC DBA ORTEGA CONSTRUCTION
17811 SLOVER AVENUE
BLOOMINGTON, CA 92316
Fee Description Oft Amount(81
Building Permit Issuance 1 27.00
Demolition Permit 1 140.00
GREEN FEE 1 1.00
$168.00
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 carded 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_SIdg_Pennk_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 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 Contractor's State License Law for
Professions Code ando7y license is in full force and effect. � the following reason:
License Class ` Licen Na. 5Z
By my signature below I acknowledge that,except for my personal residence
Expires Signature in which I must have resided for at least one year priorto completion of
WORKER'S PENSA710N DECLARATION improvements covered by this permit.I cannot legally sell a stmcture that I
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 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.leginfo.ca.goy/calaw.htmi.permit is issued.
Polity 11 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: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
T
Carrier .1 (I LAAICICAV `J with all applicable city and county ordinances and state laws relating to
building construction.I authorize representatives of this city or county to
Policy#WSDCO2MQ_ Expires enter the above identified property for inspection purposes.
(This section need not to be completed is the permit is for one-hundred
dollars($100)or less Date
PROPERTY OWNER OR AUTHORIZED AGENT
❑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 W
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
Cade,I shall forth witl c mply 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:FAILLI E TO SECURE WORKER'S COMPENSATION COVERAGE IS ❑Yes it4o
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(SCAQMDI?See permitting checklist
IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES forguidelines
CONSTRUCTION LENDING AGENCY o Yes P No
I hereby affirm that under the penalty of perjury there is a construction Will the proposed building or modified facility be within 10DO 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 DNo
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
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 next to the applicable item(s)(Section 7031.5 ❑Yes ❑
Business and Professions Code).Any city or county that requires a permit to Date
construct,alter,improve,demolish or repair any structure,prior to its PROP O OR AUTHORIZED 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 Contractors State EPA RENOVATION,REPAIR AND PAINTING IRRPI
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 by
an Applicant for a permit subjects the applicant to a civil penalty of noe residence or childcare facility to he RRP•certified firms and comply with
than($500). a O)r required practices.This Includes rental property owners and property
4%%%n Sn%. managers who do the paint-disturbing work themselves or through their
❑I,as owner of the property,or my employee with wages as their sole 90e e®rrployees.For more information about EPA's Renovation Program visit:
compensation,will do( )all of or( )portion of the work,and the a�C�/z�,;,'refis pf www.eoa.zov/lead or contact the National Lead Information Center at
not Intended or offered for sale.(Section 7044,Business d Professl'otts / 3-800-424-LEAD(5323).
Code;The Contractors State License Law does not appl owner of a �Q18 ❑An EPA Lead-Safe Certified Renovator will he responsible for this project
property who,through employees'or personal effort, it o _161 I the
property provided that the improvements are not intended o r Certified Firm Name:
sale.If,however,the building or improvement is sold within one yea ^ Firm Certification No.:
completion,the Owner-Builder will have the burden of proving that It was
not built or improved for the purpose of sale. M ❑No EPA Lead-Safe Certified Firm is required for this project because:
O I,as owner of the property am exclusively contracting with licensed
contractors to construct the project(Section 70",Business and Professions
Code:The Contractors State License Law does not apply to an owner of a If your project does not comply with EPA RRP rule please fill out the RRP
Acknowledgement.
IJILt l'•;!i S.yFET( PERfAIT PLAN: CHECK APPLIC TIOf•f MENIFEE
DATE: 1 PERMIT/PLAN CHECK NUMBER
4
PLANNING CASE NUMBER
TYPE: COMMERCIAL • RESIDENTIAL MULTI-FAMILY - MOBILE HOME - POOL/SPA SIGN
SUBTYPE: ADDITION ALTERATION •DEMOLITION ELECTRICAL MECHANICAL
1 - NEW PLUMBING RE-ROOF NUMBER OF SQUARES
DESCRIPTION OF WORK DEMO LI D0.9ilB 4^VV kE(11P&NtE • 914 Fpy$ &0*f)p-1)
Kp'rf'i. CitV Of
Uifdin r e
PROJECT ADDRESS o��'�6p� JcET �A'D p j1y)'G'F`�/yEE zlp _ g �e f.
ASSESSOR'S PARCEL NUMBER �5�7-J"�O ���� LOT TRACT AUG 16 20 8
OWNER NAME yEPolriA tRIJW/-r�/ ri l /� _
ADDRESS O 5. ' /owl' .7*/T'%A R (q/Yf
PHONE V19— 691 EMAIL rr>,vn 9/® Crm
APPLICANT NAME
ADDRESS
PHONE EMAIAIIL.�
CONTRACTOR'S NAME L�rRI,(i'S 0T A,�yI��J�/v�ll OWNER BUILDER? YES ONO
BUSINESS NAME oRr �i /�49wi/Ik�O��A),,--.,.,��ryry• �1
ADDRESS /�,}?411 sWy /7vP 6EiI/MI�� lO/E'
PHONE "!A- EMAIL / f
CONTRACTOR'S STATE LIC NUMBER 71gogiJ I LICENSE CLASSIFICATION �p up^��p
VALUATION$ _ SOFT �,?*• o�/Ta"y LSQFT 3V /`o
APPLICANT'S SIGNATURE DATE
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DEPARTMENT DISTRIBUTION I ACCEPTED BY: CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERI G FIRE
INVOICE TOTAL I GREEN , SMIP X
OWNER BUILDER VERIFIED - YES NO DRIVERS LICENSE k NOTARIZED LETTER YES NO
City of Menifee Building &Safety Department 129714 Haun Rd., Menifee CA 92586 (951)672-6777
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ENIFEE
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AUG 16 2018
Received
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CITY OF MENI�EE
BUILDING A SAFETY DEPARTMENT
PLAN APPR VAL
REVIEWED$Y DATE
I
'^ Approval of these plans shall not be construed to be a permit for,or an
e Of City
approval of,an".1 ioladon of any provisions Of the approved flans must be kept on the
regulations andOrdi� as This set of P
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NON-HAZARDOUS 1.Generator 10 Number 2 Page 1 d 3.Emergency Response Phone 4.Waste Tracking Number 1
WASTE MANIFEST CAC002973023 'I 4650S
5.Generators Name and Mailing Address Generator's She Address(if different than mailing address)
DE4N[NE liMAURENCE TRUST
1418 S.FlD•n'er Street 27781 Scoli Rd.
Sala Ana.0A-, Q704 USA ply i(qp,(�A 192=84 u*.A
Generators Phone: 714-501-5932-6IVP
6.Transporter 1 Company Name U.S.EPA ID Number
BRIC;:LF)'ENV.957 REECE S?-SAN E.ERNARDINO 92411 909-888-2DIO 53'17
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7.Transporter 2 Company Name U.S.EPA ID Number
EC:TI 952 P._ECE ST.SAW W.F'AP%DINO CA 92411 90?-E84-7424 CARO00045064
8.Designated Facility Name and Site Address U.S.EPA ID Number
LA PAZ COUNTY LA,NDMIL
26999HIGHRad�1Y96PAILEPOST 1213 A?R0L'O5ZG@I52
PARKER, A7. 85344 USA
Fact! a Phone: P�a..sra)4rle
9.Waste Shipping Name and Description 10.Containers 11.Told 12.Unit
No. Type Quantity W11Va1.
1.
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13.Special Handling Instructions and Addibonai Information
SUR.BTSiNrNY'16/-6 •PROFILE5924Y9631 IVF EPA RwG ION!X75HA1JTHORPJE STREET.ShilfRfihlCl CO.CA:13105
<t-14P,9SOUTIiCOASTt.1rf7?18f5! .^URLEl`6R!`:lEDiµMOND BAR,CA91765(909)39G-2336.04FRGFNCY
CONTACT'IMPOTRAC.ACCOUPN &73732
14.GENERATOR'S/OFFEROR'S CERTIFICATION:1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified.packaged,
marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governments]regulations.
GeneratordOfferar's PdntediTyped Name Signature Month Day Year
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15.International Shipments ❑Im Import to U.S. ❑
z p Export from U.S. Pod of entry/ex8:
Transporter Signature far exports only): Date leaving U.S.:
w IS.Transporter Acknowledgment of Receipt of Materials
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17.Discrepancy
I 17a.Discrepancy Indication Space ❑Quang ❑Residue ❑Partial Rejection ry ❑Type I ❑Futl ReJedion
Manifest Reference Number.
r 176.Alternate Facility(or Generator) U.S.EPA 10 Number
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u Facility's Phone:
w 17c.Signature of Ahemals Facility(or Generator) Month Day Year
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18.Designated Facility Owner or Operator.Cetificallon of receipt of materials covered by the manifest except as noted 1n Item 17a
Pdntedrtyped Name Sgraure Month Day Year
169-BLC-0 5 11977(Rev.9/09) GENERATOR'S/SHIPPER'S INITIAL COPY
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-OD39
UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number
WASTE MANIFEST {;,.r':�-,-_,: I +tJ,��':.:`? v` _t_a: FLE
5.Generators Name and Mailing Address Geneator's Site Address(it different than mailing address)
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6.Transporter 1 Company Name U.S.EPA ID Number
1,1'"iVfi'....i ti6ly! ti'."7 i+U31:is VFaAl'L f,F RiN ARLAN0 S124 l l U08-:;817-::O S•'i i; •"triD0i:75'3 i7?
7.Transporter 2 Company Name U.S.EPA ID Number -
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B.Designated Facility Name and SiteAddress U.S.EPA ID Number
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ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers if.Total 12.Unit 13.Waste Codes
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14.Special Handling Insbuclions andAddtional Information
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15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged,
marked and labeleclioacarded,and are In all respects in propercondition for transport according to applicable intemational and national govemmental regulations.If export shipmentand 1 am the Primary
Exporter,I certify that the contents of Ibis consignment conform to the terms of the attached EPAAcknowledgmenl of Consent
I certify Thal the waste minimization statement identified In 40 CFR 262.27(a)of I am a large quantity generator)or(b)(if I am a small quantity generator)is We.
GeneralorsfOgerors Printed/Typed Name Signature Month Day year
j 16.International Shipments
r- ❑Import to U.S. ❑Export from U.S. Port of entrylexit:
Z Transporter si nature for exports only): Date leaving U.S.:
Of 17.TramporterAcknowledgmenl of Receipt of Materials
Transporter l Pdnteciffyped Name Signature •„ 7f j .� /• on ay ear
aTransporter 2 Prinlecirryped Name Signature Monm uay Year
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} 18.Discrepancy
18a.Discrepancy lndicadim Space ❑ Quantity El Type El Residue ❑Partial Rejection ❑Full Rejection
Manifest Reference Number.
F 18b.Alternate Facility(or Generator) U.S.EPA ID Number
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w 18c.Signature ol'Altemate Facility(or Generator) - Month Day Year
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19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)
i. 2 3. 4.
20.Designated Facility Omer or Operator..Certification of receipt of hazardous materials covered by tire manifest except as noted in Item IBe
Prinledrryped Name Signature Month Day Year
EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY
CALIOSHA ASBESTOS NOTIFICATION City of Menifee
BRICKLEY CONST.CO., INC.dba Building Dept.
BRICKLEY ENVIRONMENTAL
957 REECE STREET AUG 16 2018
SAN BERNARDINO, CA 92411
TEL: (909)888-2010 FAX: (909) 381-3433 Q�+® ` p
CAL/OSHA LICENSE NO. 610414 ,R`GVGI V Gd
DEPT.OF INDUSTRIAL RELATIONS ASBESTOS CERT.A-6005
ADDRESS: San Bernardino District Office DOSH REGISTRATION#49
464 W.4th Street, Ste. 332
San Bernardino, CA 92401
DATE: 07/26/2018 JOB#: 16464
NAME/ADDRESS OF EMPLOYER: Surjit Singh
15320 Mesa View
Friant, CA 93626
ADDRESS OF JOB SITE: Vacant SFR-Scott Road
27781 Scott Road
Menifee, California 92584
JOB LOCATION: Throughout
NEAREST CROSS STREET: Zeiders Rd.
NAME OF CERTIFIED SUPERVISOR:AGUAYO/CRUZ/RIOS/PATRIZ/BRICKLEY/FIELDS/ DE ANDA!LERMA
NAME OF QUALIFIED PERSON IN CHARGE OF AIR MONITORING, LAB WORK AND
RESPIRATORS: AS ABOVE AND L.Y. ENVIRONMENTAL OR CONTRACTED C.A.C./I.H.
JOB START DATE: 8/13/2018 JOB COMPLETION DATE: 8/13/2018
DESCRIBE SCOPE OF JOB AND WORK PRACTICES (Inc.sq.ft.): Scrape,wet&remove in sections
approximately 150 sq ft of linoleum,20 sq.ft.of roofing, 53 sq.ft. of transits.
ESTIMATED NUMBER OF EMPLOYEES ON JOB: SUPERVISOR+4
EVALUATION OF POTENTIAL FOR EXPOSURE: MINIMAL EXPOSURE-RESPIRATORS AND
PROTECTIVE CLOTHING WORN THROUGHOUT PROJECT.
TRANSPORTED BY: BRICKLEY CONST.CO.,INC.dba
BRICKLEY ENVIRONMENTAL
U.S.E.P.A.#CAR000053173
STATE HAULER#2599
AND/OR
E.C.T. I.
U.S.E.P.A.#CAR000049064
STATE HAULER#3731
DUMP SITE: LA PAZ COUNTY LANDFILL
26999 HWY 95 MILE POST 128
PARKER,AZ 85344
AZC950823111
South Coast Air Quality Management District Notification Number
21865 Copley Drive,Diamond Dar,CA 91765-4182
Phone:(909)396-2336 j 23284
vnmv.agmd.gov
Rule 1403 Notification of Procedure 13 Asbestos Removal
Please maintain a copy of this Noti6mtion at the job site,either electronic or paper.
Project Type
Project Type Asbestos Removal Project Urgency Routine
Completed By (Cathleen Herrera Phone Number (909)888-2010
Contractor Information
Company Name BRICKLEY CONSTRUCTION CO Address 957 REECE ST
INC,BRICKLEY EN
City SAN BERNARDINO State CA
Zip 92411
CSLB License;? 610414 OSHA REG n 00049
Supervisor;:) Alfonso Pius Phone (951)202-0234
Supervisor k2 Allen Fields Phone (951)295-7792
Supervisor#3 Dane Brickley Phone (951)295-7216
Supervisor 114 Francisco J.De Anda Guerrero Phone (951)533-1096
Supervisor;5 Henry Patriz Phone (951)533-7016
Supervisor#6 Martin Cruz Phone (951)202-7077
Supervisor e7 Rafael Aguayo-Salazar Phone (951)533-4339
Supervisor n8 Steven Lerma Phone (951)295-8616
Site Information
Site Name Vacant SFR-Scott Road Project 16464
Site Street 4 27781 Street Name Scott Rd
Cross Street Zeidem Rd Site County Riverside
City Menifee State CA
Zip 92584
Contact Name Paulette Contact Phone (714)501-5932
Site Owner Deanne Lawrence Trust Owner Address 1418 S.Flower Street
City Santa Ana State CA
zip 92704
Project Start Date 8/13/2018 Project End Date 8/13/2018
Project Work Shift(s) Day Building Size in Sq.ft 1800
Number of Floors 1 Building Age(years) 58
Number of Building/Dwelling Units 1 Building Prior Use House
Asbestos Survey Yes Asbestos Found Yes
Asbestos Removed No Building to be Demolished Yes
Describe Work Asbestos Abatement Describe Work Location Through-out
Project Information
Asbestos Information
Amount of Asbestos in each type in Sq.Ft
Acoustic Ceiling 0 Linoleum 150 Insulation 0 Fire Proofing 0
Ducting 0 Dry Wall 0 Mastic(Non-friable) 0 Floor Tiles(Non-friable) O
Transite 53 Roofing 20 Stucco 0 Plaster 0
Other(friable) 0 Coal Tar Wrap 0 Mastic(Friable) 0 FloorTile(Friable) 0
Other(non-friable) 0
Asbestos Amount to be Removed in Sq.F1
FRIABLE 1S0
CLASS I 73
CLASS II 0
Total 223
Asbestos Removal From Surfaces,Pipes Control Procedures 1,3
Asbestos Detection Procedure(s) Survey
Waste Information
Waste Transporter Sl BRICKLEY ENVIRONMENTAL
Address 957 REECE ST. City SAN BERNARDINO
State CA up 92411
Waste Transporter#2 ECTI
Address 953 WEST REECE STREET City SAN BERNARDINO
State CA Zip 92411
Waste Storage Site BRICKLEY CONSTRUCTION CO INC,BRICKLEY EN
Address 957 REECE ST City SAN BERNARDINO
State CA Zip 92411
Landfill La Paz County Landfill
Address 26999 Highway 95,Mile Post 128 City Parker
State AZ Zip 95344
Fee Payment
Total Amount of Asbestos to be Removed in sq.ft 223
Tracking Number 3321429
Project Size Fee 62.92
Additional Fee 0
Total Fee $62.92
Payment Made $62.92
Balance Due $0
By clicking the Sign&Submit button,I certify that an individual trained in
the provisions of SCAQMD Rule 1403 and the Asbestos NESHAP(CFR
Title 40,Part 61,Subpart M)will be onsite during the demolition or
renovation and evidence that the required training has been accomplished
by this person will be available for inspection during normal business
hours.In addition,I certify that all of the information contained herein
and information submitted with this Notification is true and correct