PMT18-04420 City of Menifee Permit No.: PMT18-04420
29714 HAUN RD.
MENIFEE, CA 92586 Type: Residential Plumbing
MENIFEE MENIFEE Date Issued: 0 911 012 01 8
PERMIT
Site Address: 26733 POTOMAC DR,MENIFEE,CA Parcel Number: 338-181-006
92586 Construction Cost: $2,479.00
Existing Use: Proposed Use:
Description of REMOVE AND REPLACE 40 GALLON GAS WATER HEATER-SAME SIZE AND LOCATION
Work:
Owner Contractor
NANCY BARGASSAR AFFORDABLE WATER HEATERS AND PLUMBING
26733 POTOMAC DR INC
MENIFEE, CA 92586 28358 CONSTELLATION ROAD#698
Applicant Phone: 8553459087
AFFORDABLE WATER HEATER License Number: 627368
AFFORDABLE WATER HEATERS AND PLUMBING INC
28358 CONSTELLATION ROAD#698
VALENCIA,CA 91355
Fee Description Qtv Amount
Residential Water Heater 1 83.00
Building Permit Issuance 1 27.00
GREEN FEE 1 1.00
General Plan Maintenance Fee-Plumbing 1 4.15
$115.15
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_Bidg_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 12 my license is in full force and effect. !X' the following reason:
License Class zzzzL ��1��1 ��/J��/ ������''h License Na. v By my signature below I acknowledge that,except for my personal residence
vvvv��,��, ,,,,,,'�����11
Expires Signature t in which 1 must have resided for at least one year prior to completion of
WORKER'S COMPENSATION DECIARATI N Improvements covered by this permit.I cannot legally sell a structure 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
this permit is issued. www.leginfo.ca.gov/calaw.html.
Policy# Date
1 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 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
r with all applicable city and county ordinances and state laws relating to
Carrier y'Srr LJ�� IaIn� 'D ��5 1 p huild(ng construction.I authorize representatives of this city or county to
Policy#W�y"J✓lZ"IG1� Expires �� � � f 1 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 AG ENT
o I certify that in the performance of the work for which this permit is issued,
I shall not employ 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'wrt�1t those provisions. p Will the applicant or future building occupant handle hazardous material ora
Applicant 6W Date -I )� ) 19 �mixture can nmg a hazardous material equal to or greater that the
amounts specified on the Hazardous Materials Information Guide?
WARNING:F ILURE TO SECURE WORKER'S COMPENSATION COVERAGE 15 ❑Yes %JNo
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
IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES Coast Air Quality Management District(SCAQMD)7 See permitting checklist
for guidelines
CONSTRUCTION LENDING AGENCY ❑yes V 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 JNo
OWNER BUILDER DECLARATIONS I have read the Hazardous Material Information Guide and the SCAQMD
hereby affirm under penalty of perjury that 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 aterialr orting.
checkmark(s)I have placed next to the applicable item(s)(Section 7031.5 oyes No 7
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 0 ER OR AUTHORIZED AGENT
issuance,also requires the applicant for the permit to file a signed statement It
that he or she is licensed pursuant to the provisions of the Contractors State EPA RENOVATION.REPAIR 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($SOOI. managers who do the paint-disturbing work themselves or through their
❑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( Fall of or( )portion of the work,and the structure is www.epa.aov/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 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 issold within one year of Firm Certification No.:
completion,the Owner-Builder will have the burden of provingthat it was f,
not built or improved for the purpose of sale. G o EPA Lead-Safe Certified Firm is required forthis 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
� I A 1 1 \L� �,, `A-I,- ,b��f/���}—�Acknowledgement.
l�J✓ 1�K' 1 NJP_T� n r�'C\� F""
BUILDING & SAFETY PERMIT/PLAN CHECK APPLICATION MENIFEE
DATE: PERMIT/PLAN CHECK NUMBER O�
PLANNING CASE NUMBER
TYPE: O COMMERCIAL RESIDENTIAL O MULTI-FAMILY C MOBILE HOME O POOL/SPA O SIGN
SUBTYPE: O ADDITION O ALTERATION O DEMOLITION O ELECTRICAL O MECHANICAL
O NEW LUMBING -0 RE-ROOF NUMB`IE�ROFSQUARES
DESCRIPTION OF WORK IAC(— Yl \� �1�'f `'] U
c7knn �L�
PROJECTADDRESS J) ) � �0 11OVV\ i'\(. J 1 ZIP 7 J
ASSESSOR'S PARCEL NUMBER LOT TRACT
OWNERNAME N A>)("f CG M,
ADDRESS ((1c,� ]�I -'7 G oTJ7
PHONE "1 j 17 ( I )2; (//Z EMAIL
APPLICANT NAME HJ�.D46j/b {A,-F,e
ADDRESS ¢�'� C,)"\ s rajATIOL 1 �l ACb --lC �7 913S5
PHONE V 5S 3'"1� qJ �l EMAIL UiR1 5T � W IA p
CONTRACTOR'S NAME S Av1E /j -P LI(J n-r OWNER BUILDER? O YES NO
BUSINESS NAME
ADDRESS Building Dept.
PHONE EMAIL SEP 10 In"
CONTRACTOR'S STATE LIC NUMBER W 7 3 L g LICENS LASS551F`IIC`ATION L
VALUATION$ Z ('�� SQ FT . ';
APPLICANT'S SIGNATURE DATE rJ
TTY STAFF USE 0
DEPARTMENT DISTRIBUTION ACCEPTED BY: /mot /� CITY OF MENIFEE BUSINESS UCENSE NUMBER
BUILDING PLANNING ENGINEERING FIRE
INVOICETOTAL GREEN F SMIP
OWNER BUILDER VERIFIED OYES 0 NO DRIVERS LICENSE# NOTARIZED LETTER O YES O NO
City of Menifee Building &Safety Department 129714 Haun Rd., Menifee,CA 92586 (951)672-6777
G,tv oe -
www.cityofmenifee.us
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A F F O R D A B L E
WA)70 1 HLEA M)19
AND PLUMBING INC .
Date: August 16, 2018
LETTER OF AUTHORIZATION
"I, undersigned, give permission to accept any of the signatures that appear below, on a
permit being issued, in lieu of my signature at the counter. I hereby certify under penalty
of perjury, that I will comply with all declarations and agreements on the permit, which
bears my signature or my representative signature, and as required by the city."
The following authorized representatives have my permission to sign and take receipt of
construction permits in the name of my company:
Josiah Wotila
LeonceRorcr (� 2-0 f
Contractor Name C I �
ontractor Signature to
Contractor Information:
Affordable Water Heaters & Plumbing, Inc. Phone: 855-345-9048
28358 Constellation Road #698
Valencia, CA 91355
Contractors State License Number: 627368- Class C 36
Workers Comp Insurance:
Insurance Company of the West WSA503249702 Exp. 1.1.19
See Attached Callfornia
Acknowledgment
28358 Constellation Road, Suite 698 • Valencia, CA 91355
(855)345-9048 • FAX: (661)259-9556 • www.waterheatersandpiumbing.com
CA State Lic#627368
A notary public or other officer completing this certificate verifies only the identity of the individual who
signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of
that document.
ALL PURPOSE ACKNOWLEDGMENT
STATE OF CALIFORNIA }
COUNTY OF
On /� /�� joy pbefore me, �1117 e,2242 /i c n Notary Public,
(here insert name and title of the officer)
/
personally appeared
who proved to me on the basis of satisfactory evidence to be the person(s)whose name /are
subscribed to the within instrument and acknowledged to me that&/6heAhey executed the same in
Ons}he-rhe authorized capacity(4es), and that b}�ke4t ieir signature(s) on the instrument the
person(&), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal. sw,aoNFI FaJcc
-�` Notary Puak—cattomia
w<. - Las Anyeies corny �
C=ni55.'On 4 2227E0
tLt Comm Eniras Jan 14.2022
Signature: Lfi1��/ ��J'/�.�e (Seal)
OPTIONAL
Description of Attached Document Title or Type of Document: / (/p -,105,�/
Number of Pages:1 �)
Document Date: 114t, 6
Other:
United State,Apostille Service.authentication_le_•aliraion.Sactanientu Notar} l:s&I i