DEMO (9902-016)55400 Madison St
9902-016
LICENSED CONTRACTOR DECLARATION
ij):. - Ihp-reby affirm under penalty of perjury that I am licensed under provisions of,,
I- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
c4 W Professionals Code, and my License is in full force and effect.
O =) c'0 License # „e, - Lic. Class Exp. Date
' W —
oZ r- Date # Signature of Contractor
co
O6 V i
J U (0 OWNER -BUILDER DECLARATION
HLU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z ( ) 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).
C0 () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
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22, z WORKER'S COMPENSATION DECLARATION
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I hereby affirm under penalty of perjury one of the following declarations:
Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X Ld Y= 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 I have and will maintain workers' compensation insurance, as required by
C5 U Q , Section 3700 of the Labor Code, for the performance of the work for which this
0 Z permit is issued.t My workers' compensation insurance carrier & policy no. are:
Carrier L e Ct -K: i N`:.. t e? Policy No. VIC, !
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(This section need not be completed if the permit valuation is for $100;Q0: 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 provisions.
/Date: (!'3 f . JAPPIicant "'. f , `f M4 0
VWarning: 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 toA
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
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 for inspection urposes.
G
Signature (Owner/Agent) ; ( •( Date
BUILDING PERMIT PERMIT#
DATE VALUATION Sjft) LOT TRACT
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
KSt D V L OV"MM17 CORP
EMIER,YP1DCLfiA , IG
J-` ''LU 'Cri , BL IM
2660 ROPPER M 51 ,
LAf?C3iN"CA CA 92253
IN0I(►HILLS CA 91741
(760)345-4746 CBL,#
USE OF PERMIT
r s y
GEMOLMON OF! 11MU01 (HOUS )
Ris .N a r:rs tL a 10CWT 00
0.00
DE'M OLtTICYN kEC 4011-000-423-0I0
ii
S3JT3-1Vr 1, G.'`I')NSTR.t. MION ASCD PLAN CHECK
n LESS PRETAIDFFES
$0.(X)
Del E -NOW
$45.40)
RECEIPT J
DATE
BY C j(
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I 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
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test r
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
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)
COMMENTS:
SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT
NOTIFICATION OF DEMOLITION OR ASBESTOS REMOVAL
21865 E CoNe Drive Diamond Bar CA 017RC 402 9
W1 396-2000 "2pjfwww.aqma.qov
AaQ11D USE' ONLY :. SCREEN BY RECEIVED POSTMARK ENTERED BY NOTIFICATION &
COMPLETED.BY Wrl COMPANY NE'' (p b
DATE 3 CHECK #/ FEE $ :mfg>0 lJ PROJECT # c, '
NOTIFICATION TYPE 0(BpNAt
REVISION DATES Rmsm OTHER (highlight) CANCELLATION
PROJECT TYPE MOLMON
ORDERED DEmouTION RENOVATION (removal) EMERGENCY REMOVAL PLANNED RENO (annual)
SITE INFORMATION SITE NAME
vitvmx
SITE ADDRESS LIM.nom
CITY
CROSS STREET A%r 04 t
STATE ZIP COUNTY 1. 4 rs, If—
DESCRIBE WORK LOCATION
1 l J
BUILDING SIZE (SOFT) 1 D50
NUMBER OF FLOORS BUILDING AGE (YEARS) ? D NUMBER OF DWELLING UNITS
BLDG PRIOR F PRESENT USE
CoW XK
HOSPRAL It OUSTRM Ofhdr OFFICE PUBM BLDr,OOL SHS UNNICOLLEGE
SITE OWNER
CITY
L STATE
ADDRESS ! 54A-
61 J
ZIP CONTACT \ PHONE (504 - I I
REQUIRED BUILDING
INFORMATIONPRESENT?
ASBESTOS YES 0
ASBESTOS YES NO ASBESTOS YES NO
SURVEY? REMOVED?
BUILDING TO BE S NO
DEMOLISHED? ,
PROJECT DATES
START
a END WORK SHIFT (arn/pm)
ASBESTOS AMOUNT TO BE
REMOVED (in square feet)
FRIABLE
CLASS I
CLASS II
TOTAL REMOVED(add row)
ASBESTOS REMOVED FROM
SURFACES L a PIPES COMPONENTS
DESCRIBE TYPE & AMOUNT OF
ASBEST
ACOUSTIC CEILING
)
LINOLEUM
INSULATION
FIREPROOFING
DUCTING
^ h
1, ► lf.
MASTIC
FLOOR TILES (VAT)
DRY WALL
PLASTER -
TRANSITE
ROOFING
l
OTHER
I (describe)
CONTRACTOR pIFORMATION
CSLB LICENSE # 003 93 OSHA REG # AQMD ID # , Wq 35
NAME t–j j 6
( ADDRESS l
CITY 2)",a STATE
ZIP ' SITE SUPVR PHONE ° 3y"f-tt/j yrs
WASTE TRANSPORTER flet
LANDFILL
ADDRESS
ADDRESS
CITY STATE
ZIP
CITY STATE zip
Rule 1403 and NESHAP Asbestos Notification Form REV 9706201403FR97 Page 1 of 2
Fams, in*ucti n NO ft Rule 1403 can be obtain via FAX -BACK by dialing from a Wphone (909)396-2550 or through ACMD web site htW:Uwww.agmd.govlpntlazback.hW
:si ay
IL
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CERTIFICATE
C0MPLETI0IoICD
This is to certify that an asbestos abatement project has been completed at
55-400 Madison Street, La Quints, Ca 92253
,j.
Scope of Work:
--
.'
Removed dispose of all extereor stucco from vacant house. Approximately 1,844 slf.
'•eco::.
_Y.
a
Z . -: February
•,
16, 1999
:_
S Ya,
wa4.:: Date
_ .SIS .
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Company RepresentativeRE
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P.W. STEPHENS, INC.
Jdi Nambea: OR -10461
lob Name: son S -4@0 Madison St.
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