0401-128 (DEMO)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and �!
Professionals Code, and my License is in full force and effect. t
License # Lic. Class Exp. Date
63200 C'21 � 12/'31/0!
Date _ O Signature of Contractor �! %."✓7
OWNER -BUILDER DECLAR/k ION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier UTATI? Mff) Policy No. 124AID-03
(This. section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation �provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those p ovlslons.
Date: 1 ` 15 -" Applicant A�I/ t4e&"
6�
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such I
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property fopinspection purposes.
Signature (Owner/Agent) w � Date
.%r
BUILDING PERMIT PE MITT;
>G.7E VALUATION LOT � TRACT
JOB SITE
ADDRESS 79L999 OLD AV .NT52
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
LA QWWA:�.'tlE ,OPM.Wr.A.CsENCY
YOL44CPU LAND CLE AF%12 G
P.O. BOX. 1504
82-910 BEMMM DPL
LA QYJ NT,A. CA 42.253
T1TX12W11 CA 92274
060)398-0854 CIBLA01 2809
USE OF PERMIT
MAMMON
DtT,MU OF1JfJ1.3, FLr21, 1bSAi;td'.CkldltllC.ft PiJIL�t3i14C1 �i1U'NK' 130I.i3E
EbTEVIA RP, COST OF CC}TWIRUC'i'ION
0.00
Yl+R.M`r, M gum.ftlrty
pEMOI.-IT10N FTE 101-000-4-23-000 $45.00
r� � ✓ N � � .. r. N r .�.
MEM PRY -PAID MEMO
SCI -00
JAN 15 2004
CITY OF LA (}UINTA j
IE
W=P
`/
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BY /
DATE FINALEDINSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts -
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K-to Wrap.
F.A:U.
Framing ?
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines _
Party Wall Firewall
Exterior Lath
Drywall -.Int. Lath ,
Final
Final
POOLS - SPAS
:. BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bo OBeam
Approval to Cover
"
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping .
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit. -
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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SCAQMD NOTIFICATION OF DEINOLMOAN OR AUESTOS REMOVAL
IfI X ORIGINAL TO SCAOMID. ASB SMS NOTTFICATIOUIS, FILE i 11111r941, LOS ANGELES CA 90074.941
P.3/5
WME TI"pOpnstas
wAsra ITaRAt3E LITE
AMP=
ADt?RES>s
CITY STATE ZIP
CITY STATE ZIP
CONTROLS: DESCRIBE yVM PRACTICES AND CONTROLS TO BE USED AT THE RENOVATION AND DEMOLITION SITE. Proo®dttre M 1, 2, 3, 4, 3 or Other.
For wbaetoe ranwv* doe the ao "Wna m of Rule 1403 procedwtis used. Procedure 4 and 5 submit pWw for AQMD priar approval.
ASN' U1= DETECTION PROCENNE: CIRCLE THE PROCEDURES AND ANALYTICAL METHODS
USED TO DETERMINE ASBESTOS IN THE BUILDING;
Bulk Sampi tD, Inepedion, Sw148y, PLIW, PCNL, TEM, Assumed as Asbestos, Oalaft
Other.
FOR DEMOLITIONS GIVE THE COMPANY NAME AND WES OF THE ASBESTOS REMOVAL � i � � �� —�' �', is w. or^ fp /
/— -- i
FOR ORDERED D=LfTION SEND A COPY OF THE ORDER AND GIVE THE AGENCY NAME 6 PHONE at
AUTHORIZING PERSON:
OATS OF 0 TREE
DATE ORDERED TO BEGIN:
FOR EXEROPW ASBESTOS REMOVAL ONE THE NAME AND PHONE NUM9ER OF THE POWN DECLAKWOVAUTMOR121NG THE E
EMEAMICY AND DESCRIBE THE SU@0. UNEWECTED EVENT MERGENCY, DATE AND HOUR Of
W
EXPLNN NOW THE EVENT -WOULD CAUSE UN84kFE CONDRION6, EQUIPMENT DAMAGE OR UNREASONABLE Fd WrCIAL BURDEN;
CONTOGEWY PLAN. DESCRIBE ACTIONS AND PROCEDURES TO BE FOLLOWED IF UNEXPECTED ASBESTOS
IS FOUND DWtING pp��MOLITION NONFR1AeLE
AS9ESTOSNMTERIAL B�'.OotE CRUMBLED, KILVIERM, OR REDUCED TO Pon". /�I�r f,'c: cs
, .� j �✓c a i. S . f„
TRARM CERTIFICATM, I Cerdfy that an Individual haired in the provisions d rei;ut3tiort AQMD Rule 1403 and be will a on site du ' the removal and
,evidertor+ #0 the 190110dTralnHtp has been s000nplished by ftperw wW be SWID >te for inspection during
normal buaineaa hour,.
Cot ww Name Print ntlnte d otwterbperator Slgrtabue of ownedopa dw Tittle of ownedoper for lyase
MORMATM CERRIFICATiON: I car* That the above infamatiort is domed end 1 haw endwW any required &gwh ants.
Y44tn9'5 L414e ��,,� ky v�.nt (�F�ccn�� i 2•�5-c3
Company
Name I�IiM name of ownerbperacor Sig pe a. Tittle of owns kperata Date
No6f =fts are not woopfed without the repaired asbestos fee (AQMD Rule 301), Removals of Was than 100 square feet are exempt from notification and fees.
Please =ke dtedo Pie (v'SCAQMD'- Fees ars per noftatieon, not refundable, and vary ecc. ing to the aebestori amount to be removed. Fees are ai faltaws:
COMMQtCIAL DENIOLITIONIRENOVATION RESIDENTIAL REMOVALS 3 26.20
FROM 100 TO 1,000 SQUARE FEET $ 26.20 REVISION OF NOTIFICATION 3 10.60
FROM 1,001 TO 5,000 SQUARE FEET $ 80.10 CANCELLATION OF NOTIFICATION $ 0.0
FROM 5,001 TO 10.000 SQUARE FEET $187.10 PROCEDURE 4 OR 5 PLANS S294.00
MORE THAN 10,000 SQUARE FEET 3294.00 RETURNED CHECK CHARGE S 26.00
DEMOLITION OF LESS THAN 100 50 FT $2520 SPECIAL HANDLING FLEE $ 25.00
ATTENTION: Keep a copy of your notikAbon. State law rewires that you provide a copy of the demolition notification to Building and Safety before issuance of a
fttowton permit. For questions call 909,996.2398. For your convenience please mail the lorm and fee and do not nand carry toAOMD.
MAIL FORM AND FEE TO: SCAQMD, ASBESTOS NOTIFICATIONS, FILE 053641, LOS ANGELES CA 90074.041
TELEPHONE : (909) 399.2336 FAX: (909) 3963342 Asbe903 DemotitiordRenovelion Notification Form REV 990604 Page 2 of 2
Rami. instrudivns, and the Rub 1403 can be obtained from AQMD wsa it*. http:1twww. sq md.gov
12/29/2003 16:36 7607777011 LA QUINTA PAGE 01/01
PO Box 1504
La Qulnta, CA 92253
Phone: 790-777-7013
Fax: 760.777-7011
Fax3
To:
Rocky Young
From: Tom Hartung
Paas;
398-4594
Date: December 29, 2003
Phone;
760-777-7013
Pages:
IRS:
demo
CC: File
O Urgent 0 For Review Cl Please Comment 0 Please Reply 17 Please Recycle
Rocky, here is the info you requested:
City Address 78-495 Calle Tampico La Quinta 92253
r"
f'
Mailing PO Box 1504 La'Quinta 92253
Site Address 79-999 Old Ave 52
Contact Tom Hartung 760-777-7013
Asbestos Removal Brickley . Environmental @ Bunkhouse 12/11103, Engineering building
scheduled for 1/12/04.
Let me know if you need any more info. Thanks, Tom