PMT18-04268 City of Menifee Permit No.: PMT18-04268
29714 HAUN RD.
jF jr MENIFEE,CA 92586 Type: Pool/Spa-Residential
MENIFEE MENIFEE Date Issued: 08/3112018
PERMIT
Site Address: 28805 AVENIDA MARBELLA,MENIFEE, Parcel Number: 364-111-027
CA 92584 Construction Cost: $20,000.00
Existing Use: Proposed Use:
Description of INGROUND POOL&SPA 1154 SO FT
Work:
Owner Contractor
NICOLE ROZAKIS
28805 AVENIDA MARBELLA
MENIFEE, CA 92584
Applicant License Number:
NICOLE ROZAKIS
28805 AVENIDA MARBELLA
MENIFEE, CA 92584
Phone:9513553282
Fee Description City. Amount lSl
Swimming Pool/In-Ground Spa 1 467.00
Building Permit Issuance 1 27.00
GREEN FEE 1 1.00
SMIP RESIDENTIAL 1 3.00
General Plan Maintenance Fee-Electrical 1 23.35
$521.35
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 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 A I am exempt from licensu�re under the Contractors State License Law for
+0
Professions Code and my license is In full force and effect. the following reason: i &-e F r'7 Lvis/e7"L
License Class License No. PQ'u— By my signature below I acknowledge that,except for my personal residence
in which I must have resided for at least one year prior to completion of
Expires Signature .s��- ' Y P p
O A a improvements covered by this permit.I cannot legally sell a structure that I
WORKER'S COMPENSATION DECLARATION �a\� thQ�V a 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 folio gg eclare1,�oAs:ll� ed contractors.I understand that a copy of the applicable law,Section
have and will maintain a certificate of consent of self-insure for r''s ` 044 of the Business and Professions Code,is available upon request when
compensation,Issued by the Director of Industrial Relations as ped for V this application is submitted or at the following website:
by Section 3700 of the Labor Code,for the performance of work for which p
this permit is issued. v www.Ieelnfo.Xqov/caJ@w.html. �j n
Policy# \fe� Date `G1 - 3/` �fS
❑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 ❑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
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# Expires enter the above id tified property for inspection purposes.
(This section need not to be completed is the permit is for one-hundred �- Date v - 7 I
dollars($100)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 became 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 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 y(Fes ❑Na
UNLAWFUL,AND SHALL SUBIECTAN EMPLOYERTO CRIMINAL PENALTIES Vrill the intended use of the building by the applicant or future building
AND CIVIL FINES UP TO ONE HUNDREOTHOUSAND 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 SECNON 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES guidelines
CONSTRUCTION LENDING AGENCY Zes ❑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 99��ter boundary of a school?
(Section 3097 Civil Code) Pyles ❑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 perjury that I am exempt from the California Health BY Safety Code,Section 25505 and 25534 concerning
Contractor's License Law for the reason(s)indicated below by the hazardous mat "al repo
checkmark(s)I have placed next to the applicable Rem(s)(Section 7031.5 _
Business and Professions Code).Any city or county that requires a permit to �Yes ❑Na
Date
construct,alter,improve,demolish orrepairany structure,prlorto its PROPERTY OWNER 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 Contractor's State EPA RENOVATION,REPAIR AND PAINTING(RRPI
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
o 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).
Cade;The Contractor's State License Law does not apply to an owner of a o 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
SIMI
DATE: S ?4F 2OI8 PERMIT/PLAN CHECK NUMBER i 19` O
GRADING/PLANNING CASE NUMBER/OTHER RELATED CASES
TYPE: ®COMMERCIAL O RESIDENTIAL O MULTI-FAMILY O MOBILE HOME POOL/SPA O SIGN
SUBTYPE: (E)ADDITION O ALTERATION O DEMOLITION O ELECTRICAL O MECHANICAL
{ANEW OPLUMBING ORE-ROOF NUMBER OF SQUARES
DESCRIPTION OF WORK
OCCUPANCY GROUP CONSTRUCTION TYPE SPRINKLERS.OYES ONO
PROJECTADDRESS 288b5AVenlAA NMr1SjlA ZIP g25$4
ASSESSOR'S PARCEL NUMBER &4 I I 1 O7w7 � / LOT 1 TRACT aoses
OWNER NAME
ADDRESS '5 O Alenida a, oe rl I
PHONE C151 -355 - 320p 2 EMAIL
APPLICANT NAME Nico% Rozakl
ADDRESS 2 0r
PHONE -lf5( - '365 ' 3282 EMAIL 1 w K0Gt F4 S Q n1Q 1 I -e-M
CONTRACTOR'S NAME OWNERBUILDER? OYESONO
BUSINESS NAME City of Menifee
ADDRESS Building Dept.
PHONE EMAIL AUG 31 2018
CONTRACTOR'S STATE LICNUMBER LICENSE CLASSIFICATION (�Q�`/
VALUATION$ �i Uyyl�� SQ^FT i FjL.� LSQFf a /v��+lv ,Q
APPLICANT'S SIGNATURE I12z l T— DATE !r4 C+V1Q
CITYSTAFFUSEONLY
DEPARTMENT DISTRIBUTION ACCEPTED BY; CITY OF MENIFEE BUSINESS LICENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE
INVOICETOTAL . ✓5� GREEN I SMIP
OWNER BUILDER VERIFIED O YES 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
NI
AUG/31/2018/FRI 10: 51 AM Stacy Albelais FAX No. 951 248 0915 P. 001
August 31,2018
Re: Permits for Nicole Rozakis,28805 Avenida Marbella Menifee,CA 92584
7o the City of Menifee:
I authorize Louis Solis to Pull permits for me for the property listed at 28805 Avenida Marbella, Menifee, 6L
AW
CA 92584.
Sincerely,
Nicole Rozakis,Owner r.J
N
p
00
City of Menifee
Building Dept,
AUG 3 1 2018
Deceived
AUG/31/2018/FRI 10:51 AM Stacy Albelais FAX No, 951 248 0915 P. 002
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189
A notary public or other officer completing this certificate verifies onlythe 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 Calffo to
County of
On 2 before me, ' ` h� ✓�'�` a"I J r
Date Here Insert Name and Title of the f cer
iN 1 personally appeared palf, I\yy o?'A Is
Names)of Signer(s)
who prover]to me on the hall,If"INFartan,o 4dence to he the ner,^n(c)�nlhnsr nam®(5)IFJafe Sub66rll3ed
to the within instrument and acknowledged to me that he/she/they executed the some in his/herAhelr
authorized capacity(ies),and that by his/her/their signature(s)on the instrument the person(s),or the entity
upon behalf of which the person(s)acted,executed the instrument.
aosnEtENnsnNAsu ou ljvraa I certify under PENALTY OF PERJURY under the
Camm�ss
fission coun7r s laws of the State of California that the foregoing
MY Comm.Exppiresims 1`.A
paragraph is true and correct.
Nw 17,21561 1a41
WITNESS my hand/and official seal. /
Signature
Place Notary seal and/or Stomp Above Signature of Notary Public
OPTIONAL
Completing this Information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document I kike- 1
Document Date: Number of Pages:
Signer(s)Other Than Named Ati ve:
Capacity(ies) Claimed by Signer(s)
Signer's Name: Signer's Name:
d Corporate Officer—Title($); ❑Corporate Officer—Title(s):
❑ Partner— ❑ Limited ❑ General o Partner— ❑ Limited ❑ General
❑ Individual ❑ Attorney in Fact ❑ Individual ❑ Attorney in Fact
❑ Trustee ❑ Guardfan of Conservator ❑ Trustee ti Guardian of Conservator
❑ Other: ❑ Other.
Signer Is Representing: Signer is Representing:
C2017 National Notary Association Building Dept,
�yAUG 31 2018
0�-A r4^A"/PN R