PMT18-04933 City of Menifee Permit No.: PMT18-04933
4f 29714 HAUN RD. Type: Residential Re-Roof
,y�", y ,_- MENIFEE, CA 92586
Date Issued: 1 011112 01 8
yIEI.�(,EE MENIFEE
PERMIT
Site Address: 28223 WEST DR,MENIFEE,CA 92285
Parcel Number: 350-072-034
Construction Cost: $12,000.00
Proposed Use:
Existing Use:
Description of REMOVE 1 LAYER OF COMP SHINGLE INSTALL TIMBERLINE KDRS COLOR(GOLDEN TIMBER)
Work:
Contractor
Owner PETERSEN-DEAN INC
BRIAN HEATH 39300 CIVIC CENTER DRIVE
28223 WEST DR FREMONT, CA 94538
MENIFEE, CA 92285
Applicant Phone:5103716500
ASIA THOMAS License Number:468117
PETERSEN-DEAN INC
39300 CIVIC CENTER DRIVE
FREMONT.CA 94538
Phone:5103716500
QY Amount
Fee Description 1 27.00
Building Permit Issuance 98 98.00
Inspections not specified 1 1.00
GREEN FEE 1 4.90
General Plan Maintenance Fee-Building 1 0.00
General Plan Maintenance Fee-Mechanical
$130.90
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
as otherwise stated,a permit for construction under which no work is commenced within six
ordinance of City of Menifee.Except
ork commenced is suspended or abandoned for six months,shall expire,and fees paid shall be
months after issuance,or where the w
forfeited.
Page 1 of 1
AA Bldg_Pernit_Template.rpt
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 O 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 License No. L I y y g g p y personal residence
LClas�� 'L �— I B m signature below I acknowledge that,except far m
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 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 i www.leeinfo.ca.eov/calaw.html.
issued.
Policy# S�VIV�C_J'I.�P(� Date
1-e1'fiave 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
/ t with all applicable city and county ordinances and state laws relating to
Carrier J , �('U��G. r ' building construction.I authorize representatives of this city or county to
Policy Jl 0 Expires `7 3� 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
o 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 JJ
worker's 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 S 1 CL _n'�OYVL-[l S Date I 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 15 ❑Yes in 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 UP TO ONE HUNDRED THOUSAND DOLLARS($100,006),IN occupant require a permit for the construction or modification from South
ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR Coast AirManagement District tSCAQMDr7 See permitting checklist
IN SECTION 3706 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES fo ast Airllnes
Qua
CONSTRUCTION LENDING AGENCY inYes ❑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) o Yes ❑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&Safety Code,Section 25505 and 25534 concerning
Contractors License Law for the reason(s)indicated below by the hazardous material reporting.
checkmark(s)I have placed next to the applicable item(s)(Section 7031.S oYes in 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 AG ENT
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 fRRPI
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 Cade)or that he or she is exempt from licensure 78
receiving compensation for most work that disturbs paint in a pre•19
and the basis for the alleged exemption.Any violation of Section 7031.5 by residence or childcare facility to be RRP-certified rums and complypre-19th
than
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 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.eoa.eov/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 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. o 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.
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