DEMO (9905-232)57751 Madison St
9905-232
r 'LICENSED CONTRACTOR DECLARATION tti`
I herehy•'affirm under penalty of perjury that I am licensed under provisions of
QQ ter.9 (commencing with Section 7000) of Division 3 of the Business an
.Professionals Code, and my License is in full force and effect.
! License # Lic. Class ti. Exp. Date
:(1J(J .Ax3 C21 •/0%110(
r
ate'
l+f Ill. j ` I
Date Signature of Contractor _
,OWNER -BUILDER DECLARATION ) \
I hereby'affirmvn'der penalty of perjury, that) am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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).
as . owner of the property, am exclusively contracting with licensed
contractors•to'construct the project (Sec. 7044,` Business & Professiorials
Code).",W
( ). I'am exempt'under•Section B&P.C:'for this reason
Date, •` Signature''of Owner '
WORKER'S COMPENSATION DECLARATION
I he,rebq'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,3,700 of-theLabor. Code, for' the
performance of the work for which this permit is issued.
( )"1 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:
Carver' Policy No.
{.L C I c7' J Iida C:G ? .. , .z ; .' ' :`31.1'yt3'l 9 ,c•
(This section,'need,not be. completed if the permit valuation is for $100.00 or less).
certify that in the performance of the work for which this permit is issued,
I'shall.riot,employ any,person in any, manner so as to become. subject to the
workers'"compe'nsation laws of California, -and agree that if I should become
subjectto the workers''compensation provisions of Section 3700 of the Labor
Code I shalt) forthwith comply with thoseprovisions. {
Date ` lfdr ' Applicant, (
frC;
Warning:, Failure to secure Workers'/, ompens tion 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 perrimit 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,l have read this application and state that the above information is
correct.'l 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 propert 'inspection purposes.
ySignature, (Owner/Agent) ''y"' ( ' - •'` Date
,
BUILDING PERMIT -
`DATE VALUATION LOT TRACT
DATE
r .os ! 6d: " S.t) ;
. ,!--I-7 SI I.L•!11j r iN' c J',R . .Si C - JOB SITE
ADDRESS,
APN
' J61-0901-•.0.1. 1.'
OWNER
CONTRACTOR / DESIGNER / ENGINEER
PHYL.Ei comm''J, REAL F $",1':. TC, 'F
EMERY L.AN'DM13AR, G `
7183 NIVIYUN ,y
266W HOPPPM ROAD
CLARKSMON 101 48346
CNDIO HI LLS ' CA 92-241
`
t7C50)3454-146 Cuff ig ,
USE OF PERMIT
Gt)IvSL.1 "MILY .DOVIO ISil HOUSME
3
USTIMA' ED CaW ON? C'€2NS'1tRJMON,
ITUMT FER, Sr1MAI.MRY
C7`I 'MOLITI.O- Fa 1.01-1k)t)42MOO $45.V31
19Q8-`MT.A_L MNSTRUCLI AND PLAN Q .1, "K
UESS PRIi-s A:l )1''.E'e, S
W.00
1\ iZ x_1.1
,kECE PT/='
DATE
BY /
DATE FINALED
INSPECTOR
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)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
FnRures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
=M -E TR 0SCAN PROPER T Y 'PR 0,FI ZE=
Riverside (CA)
The Information Provided is Deemed Reliable, But Is Not Guaranteed.
*
<<<-• OWNERSHIP
INFORMATION.>>>
*
*
*
*
*
Parcel Number-
:761 090.015
S:21 T:06S
R:07E Q:SE
*
Ref Partel #
:000 000 000
Pos Interest:
*
Owner Name
:Phyle Comm R1 Est
*
COOwn.er
*
Site -Address
:57751 Madison St
Thermal 92274
*
Mail Address
:7183 N Main -St
Clarkston Mi,48346
*
Telephone
:Owner:
Tenant:
*
<<< SALES AND
LOAN INFORMATION »>
*
Transferred
:03/24/99
Loan Amount
*
Document #
:122021
Lender
*
Sale Price
:$350,000 Full
Loan Type
*
.,Deed Type
:Grant Deed
Interest Rate
*
% Owned
:100
Vesting Type
*
______________________________________
*
<<< ASSESSMENT, -AND
TAX INFORMATION
>>>
*
Land
:$308,982"
Exempt Type
*
Structure
:$65,0.92
Exempt Amount
*
Other
Tax Rate Area
:20-073
*.
*
Total
:$374,074
Taxes
:$4,515.46
*
o Impr.oved
:17
*
*
*
«< PROPERTY
DESCRIPTION >>>
*
_____________
- .
_*
Map Grid :5530
C6
*
Census :Tract:456.01
Block:5
*
Land Use :A01
Agr,Irrigated Farmland
*
Legal :8.89
ACRES M/L IN POR SE
1/4.OF SEC
*
:21
T6S R7E FOR TOTAL
DESCRIPTION
*
:SEE
ASSESSORS MAPS
*
Sub/Plat
*
Book
Page:
*
*
*
________________________
*
<<< PROPERTY
CHARACTERISTICS >>>
*
Bedrooms
Stories
YearBuilt:
AgPreserve
*
BathFull
Units :1
MiscImprv:No
*
Bath3Qtr
Bldg SgFt.:
Street .:Unpaved
ADDITIONAL
*
BathHalf
Gar SgFt
Waterfrnt:
*
Fireplce':No
Gar Type
Elect Svc:None
RmAddtns :No
*
Cntrl Ht :No
Lot Acres:8.89
Gas Svc :None
RmAddSF
* '
*
CntrlA/C :No
Lot SgFt :387,248
WaterSrce:None -
AddGarType
*
-Pool :No
Roof Type:,
SewerType:None
OthrPkng
*
*
The Information Provided is Deemed Reliable, But Is Not Guaranteed.
May -13-99 08:15A P.04
R _ LANncLEAIxc _. ? —. _... -
Et ----`
Stix / LA Qutl 'rA
AZLSA CA91702, No. 9323
AZUSA•LAND RECLAMATION (62sjs334-0719
s i 291ax JOBf 2435799'
NON-HAZARDOUS'
WASTE DATA FORM
OiA
NaMc PHYLE 00M!!QIRCIAL RM ESTATE, LLC
7183 N. MAIN STREET FPA
ADDRESS. LD.
no
CITY. STA1E. ZIP CLARRSTON riI 48346 PMpP1tf NO (760r-345-4776
ac
CONTAINERS: KXUME/Cr_ C—y — THCr,MVTDNr.
W
TYPE; ❑ TANK
TRUCK TRUCDIUMPK ❑ RUMS ❑'CARTONS Cl OTMER `
WASTE OESCPNPTION E$TQS
6ENERATIPM iROCE" RE.MV.AL .
® COMPONENTS 0/ WASTE f'f`M 9b COMPONENTS OF WASTE, _ '
T'F'M 4
W
Il'-
, DRYWALL - - 4451:5-zy
=C
.aONSTR DLBrc
a r. `
U -- '
W VOC•OVARFAI)IN(;.g A • -
A :,ITC VC RII K:A1K1N N/A • 1
PROPERTIES- PH NIA L!g. ❑ LIOUID ❑ SLUOGE ❑ SLURRY ❑ OTHER
MANDLINGTINSTUCIlo#4 .USE QF PROPER,• ItE-S-EIRATOR_Y E UIPHM
THE GENERATOR CERTIFIES THAT /rotz ~
NE WASTE AS DESCRIBER'. IS 100% 5...- +QK ( L J c Z1% _ !s /
NON HAZARDOUS TYPED OR PRINTED FULL NAME S SIGNATURE OATf
'l EPa
NAME BRICIU.EY ENVIRONMENTAL / 2) ECTI,
ADDRESS. 957 W. REECE ST / 953 W. REECE ST. 2) C A R 0 0 0 0 4 9 0 6 4
y ..n O SERVICE ORDER NA
ST ._... .
QCIT♦ ATE. ZIP . y_ R!!ldBCYs ti7.. _ /. S. BE_.tDO.a ._.9.2411 PICK UP DATE -
Q. - •-
F. ` )PHONE No t 909 ...888-2010
PEO
OR PRINTED rut t. NAME { SIGNATURE '
RUCK.UNIT.IQ a9 $84-7424 - 27 2)' DATE -
NAME AZUSA LAND RECLAMATION - ..iD C A D 0 0 9 0 0 7 6 2 6
• _. NO.
•1 CMSP03AL M&,TNOD
ADDRESS 121 • W. GLAOSTONE STREET
3 -- _ _ ❑ LANDFILL ❑ OTHER _
Q Cltr, gTATE zIP AZUSA,-CA 91702
p PHONE NO (626)334-0719
.. .. TYPED OR PAIMTF•D FULL NAME 0 Sl(jNATURF, .—.—. ...".oATE
GEN Ol0lNEW i A FOAM
rRANs S 9'
ria RTICO Mesar NONE
-- .. _.. _.— DISCREPANCY -
May -13-99 08:15A
AQM
P.02
SOUTH CC" ST AIR QUALITY MANAGEMENT nISTRICT ,
NOTIF—ATION OF DEMOLITION OR ASBESTOS RE&—..JAL
21865 E. Copley Drive, Diamond Bar, CA 91765-4182 (909) 396-2000
MAIL ORIGINAL TO SCAQMD, ASBESTOS S NOTIFICATIONS, FILE #55641, LOS ANGE_LFS, CA 90074-5641
AgMO USE ONLY _- SCREEN BY RECEIVED
POSTMARK ENTERED 13Y - NOTIFICATION # _I
COMPLETED By MYRNA COMPANY BRICKLEY ENVIRONMENTAL
PHONE 909.888.2010
DATE 4.29.99 CHECK # I ) ` FEE $ 78.60 I
PROJECT # 2435
NOTIFICATION TYPE<' na
_ r9' Revision Oates Revision Other (highlight) Cancellation +
PR I
JECTTYPE Demolition Ordered Demolition' —_--
Renovation (iem6vs . Emergency Removal Planned Reno (annual) i
SITE INFORMATION SITE NAME RESIDENCE
SITE ADDRESS 57-751 MADISON
CROSS STREET JEFFERSON
CITY LA QUfNTA STATE CA ZIP I
f COUNTY RIVERSIDE
DESCRIBE WORK LOCATION ,CEILING
• i
BUILDING SIZE (Sq. FT) 1,400 NUM86 OF FLOORS 1 BUILDING AGE (YEARS) 31 NO. OF DWELLING UNITS 1 I
BLGS PRIOR / PRESENT USE Commercial Hospital Industrial Other Office Public Bldg --.---
IResldence ,School Sh'P Unv/College
SITE OWNER PHYLE COMMERCIAL REAL. ESTATE, LLGI
ADDRESS 4790 CALLE ORONAE !
CITY LA t7UINTA
STATE CA Zip 92253
CONTACT LORI EMERY PHONE 760.345-4746
REQUIRED
INFORMAT BUILDING pRESENSSE OT YE NO ASBESTOS YES'NCI) ASBESTOS YES NO BLDG TO BE YES:'j10
INFORMATION SURVEY?
REQIOVED? MOLISH 2 -"
PROJECT DATES START 5.1399
END 5.14-89 WORK SHIFT
ASBESTOS AMOUNT TO BE FRIABLE CLASS I-
REMOVED (in square feet) 1 200 CLASS II TOTAL REMOVED (ADD ROW)
21000 3,200
ASBESTOS REMOVED FROM t9VRFACES :.) PIPES COMPONENTS
DESCRIBE TYPE & AMOUNT OF ACOUSTIC CEILING LINOLEUM INSULATION FIRE PROOFING DUCTING STUCCO MASTIC
ASBESTOS (in square feet) 11200
-LOOR TILE (VAT) DRY WALL PLASTER TRANSITE ROOFING OTHER (describe
2,000
JONTRACTOR INFORMATION 'SLB LICENSE # 610414 OS REG # 4
AgMD IDK 7639
JAME_BRICKLEY ENV1RCINeIlrMITA i - _ _
CITY SAN BERNARDINO STATE CA ZIP 92411 SITE SUPVR LARA I BRICKLEY
DARST / GOMEZ / LARGE PHONE 909-888.2010
WASTE TRA PORTER #1 BRICKLEY ENVIRONMENTAL L...—.'LL A USA LAND RECLAMATION CO,
ADDRESS 957 WEST REECE STRKG•r
CITY SAN BERNARDINO STATE CA ZIP 92411
- CITY AZUSA STATE CA ZIP 91702 I
Asbestos Demolition /Renovation Notification Forrn REV 980610 —J
Nage 1 of 2 -
May -13-99 08:15A
SCAQMD Nr`'IFICATION OF DEMOLITION OR ASBEd S REMOVAL
!NAIL ORIGINAL TO SC* D. ASBESTOS NOTIFICATIONS, FILE 065641, LO<, ANGELES CA 90074-5841
wASTE TRANSPORTER
P.03
WASTE STORAGE SITE BRICKLEY ENVIRONMENTAL i
ADDRESS ADDRESS 957 WEST REECE STREET I
CITY
STATE ZIP
CITY SAN BERNARDINO STATE CA ZIP 92411
CONTROLS: DESCRIBE MAK PRACTICES AND CONTROLS TO BE USED AT THE RENOVATION AND DEMOLITION SITE. P1dcedure\ iii 3, 4.6 or other
For asbestos removals cirGe the combination of Rule 1403 procedures used. Procedure 4 and 5 submit pians for HOMO prior approval. 01 r
ASBESTOS DETECTION PROCEDURE: CIRCLE THE PROCEDURES AND ANALYTICAL METHODS USED TO DETERMINE ASBESTOS IN THE
BUILDING. Bulk sampling, Inspection, Survey, PLM, PCM, TEM, Assumed as Asbestos, Describe Other. POLARIZED LIGHT MICROSCOPY AND
DISPERSION STAINING USING NIOSH APPROVED METHOD 07403 GEMS / INFOTOX
f
FOR DEMOLITIONS GIVE THE COMPANY NAME AND DATES OF THE ASBESTOS REMOVAL
FOR ORDERED DEMOLITION SEND A COPY OF THE ORDER AND GIVE THE AGENCY NAME: i
AUTHORIZING PERSON: TITLE
DATE OF ORDER:
DATE ORDERED TO BEGIN:
FOR EMERGENCY ASBESTOS REMOVAL GIVE THE NAME AND PHONE NUMBER OF THE PERSON DECLARING/AUTHORIZING THE
EMERGENCY, DATE AND HOUR OF EMERGENCY AND DESCRIBE THE SUDDEN, UNEXPECTED EVENT:
EXPLAIN HOW THE EVENT WOULD CAUSE UNSAFE CONDITIONS, EQUIPMENT DAMAGE OR UNREASONABLE FINANCIAL BURDEN:
CONTINGENCY PLAN: DESCRIBE ACTIONS AND PROCEDURES TO BE FOLLOWED IF UNEXPECTED ASBESTOS IS FOUND DURING
DEMOLITION OR NON -FRIABLE ASBESTOS MATERIAL BECOME CRUMBLED, PULVERIZED, OR REDUCED TO POWER. REVISED
NOTIFICATION LETTERS WILL BE SENT IF / WHEN APPROPRIATE. REMOVAL WILL BE DONE WITHIN STATE, FEDERAL, CALIOSHA. EPA
RULES a REGULATIONS.
TRAINING CERTIFICATE: I Certify that an individual trained in the provisions of the regulation AQMO Rule 1403 and NESHAP will be on site during
the removal and evidence that the required training has been accomp l by IN an w 11 be available for inspection during normal business
hours.
Ir
BRICKLEY ENVIRONMENTAL MYRNq ZEIT$
Company Name Print name of ewNerropsrator -516atur' f 91MIeir/o e t ' "r SECRETARY 4-29.99
P y6 Title of oltraer/operator Date
INFORMATION CERTIFICATION: I Certify that the above inf7ig
tiara YS rrect a
BRICKLEY ENVIRONMENTAL MYRNA ZEITS
Company Name Pant name of ewaer/operator ature
any regtitred attachments
SECRETARY 4.29-99
Title of tmrroperator Date
Notifications are not accepted without the required dsbestos fee (AQMO Rule 3011. Removal of less than 100 square feet are exempt tram notification
and fees. Please make checks payable to 'SCAQMD". Fees are per notification, not refundable, and vary according to the asbestos amount to be
removed. Fees are as follows:
FROM too TO 1,000 SQUARE FEET $ 10.40
FROM 1,001 TO 5,000 SOUARE FEET S.78.60
FROM 5,001 TO 10,000 SQUARE FEET 6183.50
MORE THAN 10,000 SQUARE FEET $288.30
DEMOLITIONS
2
5 26.20
REVISIONS
S 10.40
CANCELLATIONS
S 00.00
PROCEDURES 4 OR 5 PLANS
3288.30
RETURNED CHECK CHARGE
5
5.00
ATTENTION: Keep a copy of your notification. State law requires that you provide a copy of the demolition notification to Budding and Safety
before issuance of a demolition permit, For questions call 909.396-2336. For your convenience please mail and do not hand carry.
MAIL ORIGINAL TO: SCAQMD, ASBESTOS NOTIFICATIONS, FILE 065641, LOS ANGELES CA 90074.5641 w
TELEPHONE: (909) 396.2336 FAX: (909) 398.3342 FAX BACK FORMS: (909) 396.2550 WEB SITE: HTTP:/NWyW.AQMD GOV
Asbestos OemOhhon I Renovation NotdIcAli011 Form REV 980610
paoe 2 of 2
SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT
NOTIFICATION OF DEMOLITION OR ASBESTOS REMOVAL
218 U. Copley Drive, Diamond Bar, CA 91765.4182 909 396-2000 hftpJtvvww.aqmdgoy
AQMD USE ONLY SCREEN BY RECEIVED POSTMARK ENTERED BY NOTIFICATION i
COMPLETED BY L4r-t 6>,A.tt' COMPANY ` , PHON57(c6/eVy-i4,7(&
DATE Sbf. qq CHECK # FEE $ 6, D PROJECT #
NOTIFICATION TYPE REVISION DATES REVISION OTHER (highlight) CANCELLATION
PROJECT TYPE ION ORDERED DwounoN RENOVATION (removal) EMERGENCY REMOVAL PLANNED RENO (arm*
SITE INFORMATION SITE NAME
SITE ADDRESS v CROSS STREET 4-V4,
CITY OU104L STATE ZIP COUNTY
DESCRIBE WORK LOCATION
BUILDING SIZE (SOFT) l G d NUMBER OF FLOORS BUILDING AGE (YEARS) 6D NUMBER OF DWELLING UNITS ,
BLDG PRIOR I PRESENT USE COM AERpAL HOSPITAL INDUSTRIAL Omer OMM PUBLIC REso SCHOOL SHIP UNIVICOLLEGE
SITE OWNER
CITY STATEZIP CONTACT L M( PHONES_%%?%
REQUIRED BUILDING ASBESTOS YES 0 ASBESTOS ES NO ASBESTOS NO BUILDING TO BE ES NO
INFORMATION PRESENT? SURVEY? REMOVED? DEMOLISHED?
PROJECT GATES START { $ END ? WORK SHIFT (aMpm) 7Q^► — 6Aro.,,
LASSE
STOS AMOUNT TO BE FRIABLE CLASSI CLASS II TOTAL REMOVED(add row)
VED (in square feeQ
ST08 REMOVED FROM CRFACES' PIPES COMPONENTS
DESCRIBE TYPE i AMOUNT OF ACOUSTIC CEILING I LINOLEUM INSULATION FIRE PROOFING DUCTING STUCCO MASTIC
ASBESTOS
FLOOR TILES (VAT) DRY WALL PLASTER TRANSITE ROOFING OTHER , : ^
(discribe)
CONTRACTOR INFORMATION CSLB LICENSE # OSHA REG # AQ!AD ID #
NAME f *
ADDRESS V, 0,6 j
CITY a, S STATEjfA- ZIP SITE SUPVRqaAAo PHONE 7 34/x_( y6
WASTE TRANSPORTER II)1 LANDFILL
ADDRESS ADDRESS
CITY STATE ZIP CITY STATE Zip
Rule 1403 and NESHAP Asbestos Notification Form REV 9706201403FR97
Forms, bulfucfiorra, and Ole Rule 1103 can be obtain via FAX -BACK dia from a Page 1 of 2
by +q > orH (909) 396.2550 or through AOMD web site htWJ/www.agmd.govrprr/faxpadc.htrN