9808-068 (DSF) s LICENSED CONTRACTOR DECLARATION PERMIT# CONTROL#
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
HChapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT 9308.068TRACT 7490 Q O
CV W Professionals Code,and my License is in full force and effect. W 7/98 �,f)!) `F 9d
License# Lic.Class Exp.Date
-t !!t� 1 JOB SITE t 2 APN _
r / U �tt tti j-i l 1 e'ti3i/'9r ADDRESS 79-700 A.ti q fJ�?.50 769--7.50.005
t` 'at
-t - OWNER CONTRACTOR/DESIGNER/ENGINEER
o ZO � Date ' Signature of Contractor _ �" -
rU 6 OWNER-BUILDER DECLARATION� � "17)'FiTZ NIA 01i,SwlI` INC" YC:UNI(TS LANID CLEARING
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's 73550 ALESSAt`tDRO DRIVE,k UITH 700 82-9.10$F.i'Z\;INMUN UR.
~ IZ License Law for the following reason: PALM (A-ISURF CA J7260 `I"H I.1,6M AL. CA 92:7_i
U)
Z ( ) I, as owner of the property, or my employees with wages as their sole (7(,411399-0,104 !'8l.,fi 21900
compensation,will do the work, and the structure is not intended or offered for
sale(Sec.7044, Business&Professionals Code). USE OF PERMIT
( ) 1, 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 IjFtvii- v ALAN i W(jCll)f"FtANfU IN(NIGLI.i 1'AN11LY Q1&ELLiNG
ur)O N Date Signature of Owner
rn
0 Q WORKER'S COMPENSATION DECLARATION
o zCr I hereby affirm under penalty of perjury one of the following declarations:
LO O ( ) I have and will maintain a certificate of consent to self-insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q U ( ) I have and will maintain workers'compensation insurance,as required by
QSection 3700 of the Labor Code, for the performance of the work for which this
d U') H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
P, O 1:',(.:311'1' 9;ST11AltATI 1)CV-ST 0 1'!:0''S'IItlf.'Tlfl N
Q (This section need not be completed if the permit valuation is for$100.00 or less). 1•CRai-11T FEE SUMMARY
_J ( ) 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 the3H ►I'1t,9N FEF3 I(1l-fl+?f)-dT;- I1���J
workers' compensation laws of California, and agree that if I should become
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
/ate: Applicant ! - -
Warning: Failure to secure Workers' Compensation covera e 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. T5
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 "`�iJt 'll ."�'<I.( taN`"1"(tTJt:,1 iC��l 13NT)I'i',111V C I11'Cii �;f;tlf;
& hold harmless the City of La Quinta, its officers, agents and employees. S,
2.Any permit issued as a result of this application becomes null and void if AUG 17 1998 LESS 11101.4111111)CLS:4 tiS1 00
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation. "CC:1'UM,4"FRNIXT 14"04 IME,NOW 5,45.440
I certify that I have read this application and state that the above information is .aaITY OF , U1 NT�
• correct. I agree to comply with all City, and State laws relating to the building II�IIIIIII�IIII�IIIIIIIII 28
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes. IE
�RECEIPT DATE - By " 'r DATE FINALED INSPECTOR
Signature (Owner/Agent) � ,.r �! Date
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
Bond Beam 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) NV
ELECTRICAL APPROVALS
Temp.Power Pole
Underground Conduit
Rough Wiring r L
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp.Use of Power
C ,
Final
Utility Notice(Perm)
a
. 07/08/1998 09:43 760-398-4594 YOUNGS LAND CLEARING PAGE 05
f
f
SOUTH COAST AIR QUALITY MANAGI;l4 W DISTRICT I 1111111 111��11 11111 Jill 29
NOTIFICATION OF WAOLI TION OR ASBESTOS REMOVAL
21865E Diamond Bat.CA 91765 4182 396.2000 JNjkv
A�01Y �Y ::,.=1lr5�Nm fOtTlnNoC:.::.
COMPLEM By DESI �A�BRICKLEY ENVIRONMENTAL 01(909) 868-2010
DATE 6-12-98 01EC" [.5 FIE S 10.40 PROJECT# 1685-98
NOTFIGQT109t TYPE Remom DAm Re�scop Ottf3t{I�fpl+ q C�[wuroer
P(lOJECT TYPE Dox ma+ Ott DsommEA�m
�(Wnm*
Emotm cy RLMOVK PWNW RM(annual)
WE MFORMATM SITE NAME VACANT RESIDENCE DEMO
St>f ADDRESS 79-700 AVENUE 50 CROSS STKET
CfTY LA QUINTA STATE CA ZIP 92253 COLWY RIVERSIDE
OESCFME WORK LOCATION INTERIOR / ROOF
G Sm(m FT) 1,200 NUWXR OF RDORS 1 BULDING AGE tTAFOO 30 NUWER OF DWEIJNG UNITS 1
BLDG PRM I PRESEXI LSEWA09 n- Howffa boumm OAv Omm pim am scmm sm UwAc am
SITE OYMNFR MONTEZUMA INC. ADORES 73550 ALESSANDRO #200
crty PAIM DESERT STATE CA n DI' 92260 CONTACT ROCKY YOUNG PHONE 760-398-0854
ASBESTOS NO ASBESTOS YES NO ASBESTOS YES NO BUILDWG TO NO
B ATION PRESENT? SURVEY? REMOVED? DOrIOIlSliED?
PRO=OATU START 6-26-98 END 6-27-98 WORK SM
A88ar8TC8 AMMW TO BE FRIABLE CLASS I CLASS 9 TOTAL REMOvWfdd row)
numw(ftmwnlw� 210 210 SQ. FT.
AMEM RBWM FROM ACES PIPES OATS
DESCM TYPE i AMOUNT OF Acot;=CIBt1NG LINOLEUM MSUtATLON FIRE PROORNG DUCTING STUCCO MISM
ABEEST06
210 AT} J.DRY WALL I RASTER TRA OM OTHER
10
R"RAOTOR"' jCSLU'M' 610414 OSHA REG= 49 ACWIDA 76397
NAAE BRICKLEY ENVIRONMENTAL ADDRESS 957 WEST REECE STREET
C EY
CITY SAN BERNARDINO STATE CA DP 92411 STTESUPVR GOMEZ/GARCIA x(909) 888-2010
WASTE ER 81 BRICKLEY ENVIRONMENTAL I�NDFRL AZUSA LAND RECLAMATION CO.
ADDFESS 957 WEST REECE STREET ADOR= 1201 GLADSTONE AVENUE
CfTY SAN BERNARDINOSTATE CA DP 92411 CITY AZUSA STATE CA DP91702
Rule 14M and W-WP Asbe=Ngkabon Form REV 97M 1403FR97 Ptgt 1 of 2
Fmm omni aft and ft Rdt 14M tsn be abtdn rlt FAX SACK by a WV fom a ft*b�RM! or Woo AQW wb Ma Mp�h�wr
07/08/1998 09:43 760-398-4594 YOUNGS LAND CLEARING PAGE 06
CAIJOSHA ASBESTOS NOTIFICATION
BRICXUY ENVIRONMENTAL
957 WEST REECE STREET
SAN BERNARDINO,CA 92411
TEL:( 09)SM2010 FAX: (909) 381-3433
CALOSHA LICENSE NO.610414
DEPT.OF INDUSTRIAL RELATIONS ASBESTOS CERT.A-6005
ADDRESS: 464 W.FOURTH STREET STE 332 DOSH REGISTRATION#49
SAN BERNARDINO,CA 92401
DATE: 6-12-98 JOB# 1885.98
NAME/ADDRESS OF EMPLOYEE: YOUNG'S LAND CLI ARING
82-910 BECKMAN DRIVE
THERMAL,CA 92274
ADDRESS OF JOB SITE: _ VACANT RESIDENCE—(DEMO)
79-700 AVENUE 50
LA QUINTA,CA 92253
NEAREST INTERSECTION:
NAME OF CERTIFIED SUPERVISOR:LARA/GOMFJJBRICKLEY/DARSTA ARGENT
NAME OF QUALIFIED PERSON IN CHARGE OF AIR MONITORING,LAB WORK AND
RESPIRATORS: AS ABOVE AND GEM SERVICES
JOB START DATE: 6-26-98 JOB COMPLETION DATE: 6-27-98
DESCRIBE SCOPE OF JOB AND WORK PRACTICES(Inc.sq.ft.):SCRAPE AND REMOVE WET IN
SECTIONS AND DISPOSE OF APPROX,200 SQ.FT.OF ACM FLOOR TILE AND 10 SQ.FT.OF ROOFING_
ESTIMATED NUMBER OF EMPLOYEES ON JOB: 2
EVALUATION OF POTENTIAL,FOR EXPOSURE: MINIMAL EXPOSURE-RESPIRATORS AND
PROTECTIVE CLOTHING WORN THROUGHOUT PROJECT.
TRANSPORTED BY: BRICKLEY ENVIRONMENTAL
U.S.E.P.A.#CAL 000020974
STATE HAULER 4259
AND/OR
BDC SERVICES INC.
766 S.AYON,AZUSA,CA 91702
U.S.E.P.A.CAD981455520
STATE HAULER#1204
DUMP SITE: AZUSA LAND RECLAMATION CO-
1201 W.GLADSTONE STREET
AZUSA,CA 91702
CAD009007626
07/08/1998 09:43 760-398-4594 YOUNGS LAND CLEARING PAGE 07
BRICKLEY ENVIRONMENTAL
SUPERVISOR DAILY LOG SHEET
DATE: SUPERVISOR NAME: p 0 O L A�'R
JOB NUMBER I-?grf'' 9� JOB NAME:_YD V y,5 .Q it-b C G 97a 2/ N rr
JOB LOCATION: jl Q C a ti 9- y
0 0 1/ :"0
PRE JOB MEETING NOTES&ATTENDANCE:
r"Z /-4,1
PRE ABATEMENT STARTUP CHECK �UST:. ``'` YES NO NJ
...,....., .... .. .. .. .,:...._...,... .. ........ .::n.�,. 1. . .. .. . '�t::.,.. A
1. ENTRY/EXIT LOGS, DECONTAMINATION PROCEDURES,EMERGENCY PLAN POSTED.
2. JOB/EMPLOYEE FILES. EMERGENCY KIT, FIRE EXTINGUISHER.ON SITE.
3. RESPIRATOR BOARD UP, PROPER RESPIRATOR SELECTED/USED.
4. WARNING SIGNS/CRITICAL BARRIERS POSTED. (L T
5. AIR MONITOR ON SITE&READY.
6. WORK AREA PRE CLEANED.
7. POLLY CONTAINMENT ENCLOSURE INSTALLED.
8. DECONTAMINATION SYSTEM INSTALLED AND FUNCTIONING.
9. WATER FILTRATION SYSTEM INSTALLED. �
10. NEGATIVE PRESSURE ESTABLISHED. /
DURING ABATEMENT CHECK LIST: YES' NO NIA
1. RESPIRATORS&SUITS WORN BY ALL PERSONNEL IN CONTAINMENT.
2. WET REMOVALJ PROPERLY BAGGED ACM.
3. NO SMOKING, EATING, DRINKING IN CONTAINMENT.
4. NEPA VACUUM USED. a�
5. CONTAINMENT BARRIER WORKING PROPERLY.
6. NEGATIVE AIR PRESSURE OPERATIONAL.
cw.�atraa rworarorn,..m.e.
n//Ub/l"d kjy:43 760-398-4594 YOUNGS LAND CLEARING PAGE 08
YgSTM:j MQ MNASTE S&L BRICKLEY ENVIRONMENT
WDR ADDRM 957 WEST REECE STREET
HT1( STATE 21P CITY SAN BERNARDINO STATE CA X92411
CONT11 .8: DESCF48EWMMIAMM AND CONTROLS TO BE USED AT THE D AND RENOVATION SITE.FOR ASSF =F60VAL
WOK itl=ATE WU 1403 PROC> 61.2.3.4 OR 5 OR COMBWATIM OF
USED. FOR PROC�IJRES 4 AND S.SUE4hMlT PLANS
FOR AOMC PRIOR APPROVAL. FROMM k
18. 3
AS8IBTOS 0El ECl BNP THE METHOOS AND MXZXM USEDTO MMME WFC ASSESTOS IS PRESENt AT THE
SFT£IM=X MNG THE ANALYTICJIL METHOOS(surrey,ba tort4i'erp.inapeWon.ns nw AMA.sock
FOR DEMOLITIOM GIVE THP COWANY NAME AND DATES OF THE ASBESTOS REMOVAL
FOR O MEM DMTIIWLff ON SEND A COIy OF THE ORDER AND GIVE THE ACENV NAME:
AUTHOFONG PERSON: TITLE
DATE OF ORDER ETF OFMM TO BEGIN:
FOR El 1f ASBESTOS IiB WAL GNE TFIE NAME AND PHONE NUMBER OF THE PERSON DEq.AR1NCalAUT1i0RIIJNGIHE DATE
AND HOUR OF EMERG384CY AND DESCRIBE THE SUDOM3d.UNEXPECTED EVENT:
E)FIANd HOWL THE EVENT WOULD CAUSE UNSAFE CONDITM=.EQUIPM WI)AMAOE OR UNREASONABLE FOIANGM.BURDEN:
ffwAltCy PLAN: DESCM ACTT m AW PFtOCEDUFO TO BE FOLLOWED IF UNEMC10 ASSEM 19 141W OURlryf3 09 WT=oR NONF?""
ASBESTOS wleftmL BECOaE OFWMBLED.FMVEtt®.CR REDU=TO POWOM
TRADWO CERTIFTCATIOK I Cc*ra an k*A"*area in ft Pro 61m of moubom AaW R*tem and N MW•i ba on 1*&ft tde nam and aritrroa>l.aese
n��a aaidnD r+s been aomn+pFsrbd br Bee peiaon�a era�br.t�- aarMkp
D�
6-12-98
DATE PRAT 1S4 8519 T DATE
MCW4 iATM C8R r* AT0k t oe*VW I**m rI'm naai A is ane I row
DESIDERATA CARI)'r1II.L
6-12-98
PRII�fT NAME OF 11TOR SIGNATURE DATE
NaNi�liar>s as sot wmw the rvQtwW v*s as fm(AQMQ Ride 301j Rasrorata dIMtMMm tOd iNt w aiasnptftvm ^ZWf0L
Ple�e nadae tle�d�s psyhle b'SCAQfdD'. Fees at ver notlllpd4on, not tefundiibiR and rat► �the asbaslos amokert>A Oe rorlrorul. FMs ere as
FROM1100 TO 1=SQUARE FEET $ 10.40 S 28 0
FROM 1.001 TO 5„000 SOL AREfEET .$ 78:80 REVISIONS 3 IDA
FROM 5A01 TO 10A00 SQUARE FST 5183.50 CANCELLATIONS S 00.00
MORE TWAN t0A00 SQUARE FET fm.30 PROCEDURE 4 OR 5 PLANS 3248.30
MUM DIECI(CNARGE 325.00
IATTE nft STATE LAW OMMI NTTENOMEACOPYOFO0=Jflar11O rtMONTOY=LOM OMMANDsMFETYOST•/LEA1E'WA
COPY.STATE LAW OOUWTrir PROOFT"TTIMIIMMAT1OMNAt<>mMCEMoYAW FORYOEX=NVW=XAlLXL=WATIOFNAIDO010TIMIn
C+uaxrTWMD=AO1r HUNOSTAFFT002C ETPWL CdfMACT=AWKWUM011)MA#®NALTfMNOTVCAMK FOROAWaSCALL90a.7K M
t /L ORrWAL T'O: SCAOIItD'.RULE 1403 ASBESTOS 11M CATOM P.M 8=;NM DIALIMID W CA 917i&aW
T8 3IfM: (909)39I<•= FAX PW 3*=
Rds 1403 w4 NE&WA Aabasms NotftgDon Fam REV 9TOIiZD 1403FRV Page 2 o42
FOW&kWOU0 1L and ft Fide 14M ae be acoh v%FAX4ACK by"ban a&a 31&Moreaao AOM woo w Mopow�++OAo'r(prrlla�badct�d
U7/Ud/1'3J8 09:43 760-398-4594 YOUNGS LAND CLEARING / PAGE 09
7, PERSONAL UTILIZING DECONTAMINATION SYSTEM PROPERLY. ./
""..•••'••••••. ;.T .'�.;.!,•�wa Yf
rA: � s JkL'Lc;�:+Wiii "'x 1i,: S WO MIA
ACM DEFINED IN SCOPE OF WORK REMOVED.
I- ALL ACM WASTE PROPERLY PACKAGED, LABELED&MANIFESTED.
2. INSPECTION FOR RESIDUAL DEBRIS:
A- HORIZONTAL SURFACES'-I.E. -FLOORS, PIPES,VENTILATION DUCTING, ETC. ✓
B- VERTICAL SURFACES-I.E.-WALL, REGISTERS,WINDOWS, LIGHTS, ETC.
3. WORK AREA ACHIEVE VISUAL CLEARANCE.
4. ENCAPSULATION OF WORK SURFACES.
5- CLEARANCE AIR SAMPLES COLLECTED.
ARRIVAL TIME: //:v /1 DEPARTURE TIME:_
SCOPE OF{NORWFtELD NOTES ,1
sC7-
/t!t/ cop/F' p zX. • 6"
CIO C r~
P-ro/Z/I/k J w z/L iy /1 T.9 L 1-4c-'a
A .ti• /ZizM �� o ,� . f iii.is u acr 1y 1T71�O D i
1< oC.Q -RJ
7fZ CT1 U'40 7, 1124'
SUPERVI IGNA RE