PMT18-04264 City of Menifee Permit No.: PMT18-04264
�y- 29714 HAUN RD.
L�/A ff MENIFEE,CA 92586 Type: Commercial Alteration
MENIFEE MENIFEE Date Issued: 08/28/2018
PERMIT
Site Address: 29826 HAUN RD, Suite#209. MENIFEE, Parcel Number: 336-380-055
CA 92586 Construction Cost: $0.00
Existing Use: Proposed Use:
Description of HOURLY INSPECTION C OF O FOR GRACE FAMILY HEALTH
Work: FIRE INSPECTIONS REQUIRED
Owner Contractor
AMBER MANAGEMENT ,
29826 HAUN ROAD,STE 305
MENIFEE, CA 92586
Applicant License Number:
MENIFEE, CA
Fee Description O yt Amount(SI
Fire-Certificate of Occupancy Inspection 1 147.00
Building Permit Issuance 1 27.00
Inspections not specified 129 129.07
$303.07
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_61dg_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 70D0)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 Class License No. By mysignature below I acknowledge that,except for my personal residence
Expires 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 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 Cade,is available upon request when
compensation,issued by the Director of Industrial Relations as provided for this appli n is submitted or at the following website:
by Section 3700 of the Labor Code,for the performance of work for which
www.le fo. ov calaw.h[ml.
this permit is issued.
Policy# Date
❑I have and will maintain workers compensation insurance,as required by PROPERTY W R OR AUTHORIZED AGENT
section 3700 of the Labor Code,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 workers compensation insurance carrier and polity 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
Cartier 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 identified property for inspection purposes.
(This section need not to be completed is the permit is for one-hundred Date
dollars($300)or less 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#
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 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:FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS ❑Yes o 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 UPTO 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 ❑No
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
Contractors License Law for the reason(s)indicated below by the California Health al Safety Code,Section 25505 and 25534 concerning
hazardous material reporting.
checkmark(s)I have placed next to the applicable item(s)(Section 7031.5 oyes ❑No
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 PROPERTY OWNER OR AUTHORIZED AGENT
issuance,also requires the applicant forthe permit to file a signed statement
that he or she is licensed pursuantto the provisions of the Contractors State EPA RENOVATION,REPAIR AND PAINTING(RRPI
License Law(Chapter9(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 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
❑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.
CERTIFICATE OF OCCUPANCY/TENANT DISCLOSURE APPLICATION MENIFEE
DATE a S f pt.
BUSINESS NAME rd�� I 2� `f1� AUG 2 $ 21118
BUSINESS ADDRESS ) � eDog Received
NAMES) OF BUSINESS OWNERS t I 1 P f
PHONE NUMBER SI ')--3'� 4_qq EMAIL
CvYvl
OWNER OF BUILDING OWNER OF BUILDING ADDRESS Zge2-G l Ste DS
INTENDED BUSINESS USE O 1 CA
IS THIS A NEW BUSINESS IN THE CITY OF MENIFEE? NO (CIRCLE ONE)
ARE YOU THE FIRST TENANT TO OCCUPY THIS SPACE? YES . NO (CIRCLE ONE)
IS THE BUILDING EQUIPPED WITH FIRE SPRNKLERS? YES NO (CIRCLE ONE)
SQUARE FOOTAGE �7Cj NUMBER OF EMPLOYEES
NUMBER AND LOCATION OF RESTROOM FACILITIES
• LIST ANY TOXIC CHEMICALS, FLAMMABLE/COMBUSTIBLE LIQUIDS OR GASES USED OR
STORED WITH MSDS SHEETS AND QUANTITIES OF EACH BELOW OR ON A SEPARATE
ATTACHED SHEET(S):
btre,
• ARE YOU MAKING ANY IMPROVEMENTS TO THE SUITE OR BUILDING OTHER THAN PAINTING,
PAPERING, FLOOR COVERING, MOVABLE CASES, SHELVING OR PARTITIONS NOT OVER 5' 9"
HIGH?
YES NO (CIRCLE ONE)
Applicant agrees that the Certificate of Occupancy shall be posted in a conspic location, and will
operate subject to ttrhe, City' issuance of the Certificate of Occupancy.
1, l.( I m Phi i 145� 5 hereby agree to comply with the above-described terms
in this Appli tion of Certific of Occupancy. G
SIGNATURE V l v DATE �� l
CITY STAFF USE ONLY
APN Ifjsw. PERMIT NUMBER M"C1 LQ
INVOICE AMOUNT 3. OCCUPANCY GROUP
Staff signature required if approved to issue Certificate of Occupancy.Please write N/A if approval is not required.
PLANNING: I ENGINEERING: ISJ'
ENVIRONMENTAL HEALTH: NIA FIRE., ►nslp-
CODE ENFORCEMENT: NK BUSINESS LICENSE: I CS
City of Menifee Building &Safety Department 129714 Haun Rd., Menifee, CA 92586 (951)672-6777
www.cityofmenifee.us
NIF