DEMO (12-0072)59781 Madison St
12-0072
P O. BOX 1504.
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: 12-000-0 0072- ..
Property Address: 59781 MADISON ST
APN: 766-080-009- _000000 -
Application description: DEMO - COMML/OTHER
Property Zoning: LOW DENSITY RESIDENTIAL
Application valuation: 0
Applicant: Architect or Engineer:
Ir
°F WQut«tw
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
--------------------------------------------------
LICENSED CONTRACTOR'S 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.
License Class: A -C21 -D40 License 553327
• Datef'/ ntractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the
following reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to its 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 Contractor's State
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
(_ 1 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and
the structure is not intendedoroffered for sale (Sec. 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of property who builds or improves thereon,
and who does the work himself or herself through his or her own employees, provided that the
improvements are not intended or offered for sale. If, however, the.building or improvement is sold within
one year of completion, the owner -builder will have the burden of proving that he or she did not build or
improve for the purpose of sale.).
(_ 1 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.
7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of
property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.).
(_) I am exempt under Sec. , BAP.C. for this reason
Date:
Owner:
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the
work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name:
Lender's Address: '
LQPEPMIT
Owner:
PETCON LANDS, LLC
662 WEST GRAND AVENUE
CHICAGO, IL 60654
Contractor:
DUNCAN CONTRACTING, WARREN
2148 GLENN HELEN PARKWAY
DEVORE, CA 92407
(909)880-8501
Lic. No.: 553327
VOICE (760) 777-7012'
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 1/25/12
D d
J
JAN 201
--------------------- : --------------------------
WORKER'S COMPENSATION DECLARATION
1 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.
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 and policy number are:
Carrier STATE FUND Policy Number 2380005237
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 sh a orthwith compl ith those provisions.
te: !`17`!/2- licant:0 //1 s✓— —
WARNING: FAI[URE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($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.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and Safety for a,permit subject to the
conditions and restrictions set forth on this 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 application,
the owner, and the, applicant, each agrees to, and shall defend, indemnify and hold harmless the City
of La Quinta, itsofficers, agents and employees for any act or omission related to the work being
performed under or following issuance of this permit. -
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 county ordinances and state laws relating to building construction, and hereby authorize representatives
of this. county to enter upd the above-mentioned property f ction purposes.
Da S 2 gnature (Applicant or Agent)...
Application Number 12-00000072
Permit DEMO PERMIT
Additional desc .
Permit Fee . . . . 45.00 Plan Check
Fee
.00
Issue Date Valuation
. . .
. 0
Expiration Date 7/23,/12
Qty Unit Charge Per
Extension
BASE FEE
45.00
Special Notes and Comments
DEMO TO BARE GROUND APPROX. 1,700 S.F.
GARAGE/BARN STRUCTURE ONLY. PER BH. 2010
CODES
Fee summary Charged Paid Credited
Due
-----------------------------------------------
Permit Fee Total 45.00 .00
----------
.00
45.00
Plan Check Total. .00 .00
.00
.00
Grand Total 45.00 .00
.00
45.00
LQPERMIT
319
765
101/24/2012 10:40 760--779-0321 FEDEX OFFICE 3101 PAGE 03
ARTICLE J
TTS Opening Agt+eemcut is made and entered into this 36' day of September, by and between
PEM J. SCI33VARELLI and CONSTANCE SCHIVAREi,LX, the is tW MembUS, whose signature
appear on the signature page thereof. .
VAT4_Ql '
WHEREAS PETER 1, SCHIVARELLI filed Articles of organization for PE'TCON LANDS,
L.L.C. with the Secretary of State of California on SEPMMBER 2006,
NOW, TEERBFORE, the parties agree as follows:
DEFMTRONS
The following lame used in this Opeataing Agreement shall have tilt following ommlizo:
(a) "Act" eball mean the California Limited Liability Company Act.
(b) "Articles Of Organttation" shall mean the Articles of Organization of MCON LANDS,
L.L.C. as filed with the Secretary of State of Californias as emended firm time to time.
(c) "Capital Account" ae of any given date shall mean tete Capital Contribution to the Company by
a Membra as adjusted up to such date putmatttt to Articic V11.
(d) 'Capital Cotmtr'btttion" shall mean any contribution to flit capital of the Cotte is cash or
property by a Member wbearwer made. "Initial Capiad Contribution" shall meats the initial
conttibndon to tits capital of the Co V&V pursuant to this d►perastng Agreement.
(e) 'Code- shall mean the lnternat Revenue Code cif 1986 or corresponding pMvbions of
subsequent superseding federal ri venue laws.
(f) "Company° shell refer to PETC014 LANDS, L.L.C.
(g) "Deficit Capital Aeoount' shall mean with respect to any Member, the deficit balance, if any.
in encb Member's Capital Account as of the end of the taxable year, after giving effect to the
hollowing ad}ttstmonm:
(i) credit to awl Capital Account any amount which such Member is obligated to rcatorc
under Section 1.70-1(b)(Z)(ii)(c) of the Treasury Regtiladoes, as well as any addition thereto
pursuent to the treat to feet senteme of Seaadons 1.704-2 (g) (1) and (1) (S) of the Treasury
Regulalim, atter taking into accmuE thermmder any chauges during such year in partnership
miltim m On (as determined in accordance with Section 1.704-2(d) of the Tmamry Regulations)
and in the minimum gain attributable to any partner for non-recourse debt (as determined under
Section 1.704-2(i)(3) of the Trowury Regulations): anti
;01/24/2012 10:40 760--779-0321 FEDEX OFFICE 3101 PAGE 04
Company may locate its places of business and registered office at any other place or places as the
Members may deem advisable.
2.04 Registered Office and Registered Agent. The Company's Initial registered office shall be at
the office of its registered agent at 38225 VISTA DEL SOL RD.. RANCHO MIRAGE,
CALIFORNIA 92270, and the name of its initial registered agent shall be CONSTANCE
SCHIVARELLI. The registered office and registered agent may be changed by filing the address of
the new registered office and/or the name of the new registered agent with the California Secretary of
State pursuant to the Act.
2.05 Term. The term of the Company shall be fifty years from the date of filing of Articles of
Organization with the California Secretary of State, unless the Company is earlier dissolved in
accordance with either the provisions of this Operating Agreement or the Act.
ARITCLE III
BUSINESS OF COMPANY
The business of the Company shall be:
(a) To buy and sell and/or develop California Real Estate;
(b) To accomplish any lawful business whatsoever, or which shall at any tirne appear conducive to
or expedient for the protection or benefit of the Company said its assets.
ARTICLE IV
NAMES AND ADDRESSES OF MEMBERS
The names and addresses of the Members are as follows:
NAME
ADDRESS
PETER J. SCHIVARELLI 1352 W. WFMSTER
CHICAGO, IL 60614
CONSTANCE SCHIVA.RELLI 38225 VISTA DEL SOL RD.
RANCHO MIRAGE, CA 92270
ARTICLE V
RIGHTS AND DUTIES OF MEMBERS
5.1 Duties of Members. In the absence of a Manger, the Members agrhe to mutually undertake
responsibility for the management of the Company as such Members shall determine from time to
time.
001/24/2012 10:40 760--779-0321 FEDEX OFFICE 3101 PAGE 02
NEW ACCOUNT INFORMATION
Financial Institution Blame and Address
The PrivateBank; & Trust Company
5260 Old Orchard Rd
Skokie, IL 60077
C] TEMPORARY ED REPLACEMENT
DATE 09/29/2011 OP4NEDBY 00094 Stacy ;fheod,.
0000002 North Shore 0
ACCOUNT INFORMATION
AMOUNT OF OEFOSIT S PIAN M ACCOUNT NUMaER 2286848
TITLE OFACCOUNT Pet con Lands LLC ACCOUNT T.I.N. 45-3460164
C/O Hechtman Group
5250 Old Orchard Rd Suite 400
Skokie IL 60077
OwNSRSHIPTYPe Limited Liability Company
PRODUCTNAMp Simplified Business Checking
"ida, nuntberx or phreeee preceded by e El Pre epollcable only If thn Q Is marked.
BUSINESS ENTITY INFORMATION BUSINESS ITILING STATE Illinois
QU-'IN11;S NAME AND ADDRESS ENTITY DOCUMENT
Petcon Lands LLC LAST FILING DATE
Jay E Idechtman FILING EXPIRATION
C/O Hechtman Group DATeESTA.DUSHED
5250 Old Orchard Rd Suite 400 NATURE Of' DUSINESS
Skokie IL 60077 PRIMARY LOCATION
ASSUMED NAME IF D/b/A RESOLUTION DATE
t -MAIL ADDRES
CONTACT NAME FACSIMILE AUTI•IOR17AT10N ON PILE EI Yes NO
CONTACT TITLE LIMITED LV.BIUTY COMPANY TAX CLASSIPICATION; P
CONTACT PHONE BUSINESS ENGAGES IN INTERNET aAMOUNG'E]
OTH9R 'If box Ie Checked you moot provide evidence of eutherlty to engape in Intnrnnt Gambling.
TAXPAYER IDENTIFICATION NUMBER CERTIFICATION
Under penalties of perjury, I certify that:
1, The number shown on this form is my correct taxpayer Identification number (o( I am waiting for a number to be issued to me), and
2. 1 am not subject to backup withholding beosuse: (a) I am exempt from backup withholding, or (b) I have not been notified by the. Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding (Notice: If you ars subject to backup withholding, cross out this line), and
3.1 am a U.S. citizen or other U.S
Taxpayer Identification Number: 45-3460164
Jay E Hechtman — DATE
ADDITIONAL TERMS
IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT. To help the government fight the funding of terrorism
and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record Information that Identifies each person
who opens an account. What this means for you: When you open an account, we will ask for Your name, address, data of birth, and other
information that will allow us to identify you. We may aloo ask to sea your driver's license or other Identifying documents.
r
ACKNOWLEDGMENT. By signing this document, the undersigned acknowledge that Choy have opened the type of account designate
and have received, understand and agree to be bound by the terms of the Account Agreement for that account type. Tho undarsig
that all (nforrnation provided to the institution is true and accurate. If this Is a consumer account, the undersigned acknowledge an
Account Olsclosure, and a copy of this institution's Privacy Policy. The undornigned also acknowledge receipt, whare ap this
Institution's Funds Availability Policy and/or Electronic Fund Transfer Agreement. If this account is opened In the name of the b ity, all
signers are acting an behalf of the business entity. All signora authorize this institution to make Inquiries from any consume agency,
including a check rotection service, In connection with this account. w '•." '
OF SIONATUMS REWIRED: 1 N'
MILD ALLOWED SIg mer Only Tldel
O At•therixod 8lpnor Only TWO:
Z4.- . X
J htman Dao Peter J Schivarel.li Deta
A red Signer D , ndn:O Aavwnzed signor only Tnln:
j
L
_. C. X —
nstance SchivsrEalli' - eio Dale
t1 r-14.. F.....n... ""--- '
,........ _,._.... ..._ ._ - ...,. .....,. .. ,......1 ,•y. 1 v, c r+ra+.teYGpIIMDteyrtapt.ten
RECORDING REQUESTED BY:
••iptaft No—' TMe Company
E.a— We. •J3876 -RC
ra o a.. W. 269929274+48
when Recorded Mag Document
and Tax Statement To:
C/O Anthony J. Pauletto
PETCON LANDS, LLC
6.61 Beat Grand Avemua
Chicago. IL 654
DOC # MO -0469430
88/30/2818 86:080 Feer31.ee
Paea.1 of 3 Coe T Tax Paid
Reowded In official Rwmrds
County of Riverside
Larly Y. Hard
Rawsaor, Carly Clark 6 Rom der
I
IsIN I 1 "M
8 R U PAGE SUE DA MSC jpWG RFD COPY
M A 4 MO. A29.
CTY t1W1
GRANT DEED SPACE Ahxrvc tnw u,*........ _. ust
q /
Tinaundersigned grantoKe) dedarelsl
,
Dooumu tory transfer tax is 8'165.00:
( X 1 computed on full value of property conveyed, or
( ) computed on full value less value of liens or encumbrances remaining at time of sale,
) x 1 City of Le Quints
FOR A VALVABLE CONS119"T10N, rsoelpt of which Is hereby aelenowledged,
37 LLC,a Montana limited liability company, vho acquired title as a Montana Corp. AND
Gwendolyn Griffith . An Uwarried Woman
hereby GRANT($) to 'PETCON LANDS, LLC. A CALIFORNIA LIMI= LIABILITY CMeANY
Via following described Wal property M the City of Le Ouints, County of Riverside, Stets of California:
SEE EXHIBIT 'ONE' ATTACHED HERETO AND MADE A PART HEREOF
DATED: July 19, 2010
State of
County o
u10 before me,
Notary Public
(hem imart name and title of the officer). Personally
appeared €,wL. a.lfral,
and Gwenddtvn Griffif
who proved to me on the bass of satisfactory
evidence to be the person(s) whose names) Is/are
subscribed to the within instrument and
acknowledged to me that helshe/they executed the
Sema in hisRhertt heir authorized cepaclty(W. and that
by hisAher/dWir signature(s) on the instrument the
person(s), or the entity upon behalf of which the
person(s) acted, executed the instrumerd.
I certiN under PENALTY OF PERJURY under the laws
of the State of California that the foregoing para0c IN
is true and correct. A 2;1 +w
37 LLC, s Montana Corporation
By.94
er esidant
4-11
we►doly Gn
s
WITNESS ciai seal
Signatu EA L
ll -Qsm io 'i rf'rr'r5 9/ielac
MAIL TAX STAT TS
FD -213 (Rev 12/07) GRAM DEED
(eant•WPCO (as-"
RIVERSIDE,CA DOCUMENT: DD 201OA69430 Page 1 of 3
Printed on 1/12/2012 4:24:46 PM Provided by DataTracs System
oe
rooqq No. i374"c
Ttd. rds No. 288929274 -Se
EXHUNT ONE
THE NORTH HALF OF THE NORTH HALF OF THE SOUTHEAST QUARTER OF THE SOUTHEAST QUARTER OF THE
SOUTHEAST QUARTER OF SECTION 28, TOWNSHIP 6 SOUTH, RANGE 7 EAST, SAN BERNARDINO BASE AND
1n1€ MMAIC
APN: 76"80-009-4
RIVERSIDE,CA DOCUMENT: DO 2010 {89430 Page 2 of 3
Printed on 1N2f2012 414:46 PM Provided by DataTrace System
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SCOTT MORRISON & ASSOCIATES
P.O. Box 55329 31855 Date Palm Drive, Ste. 3#507
Riverside, CA 92517 Cathedral City, CA 92234
(909)624-1665 (760)323-7743
ASBESTOS SURVEY REPORT
Completed On
January 17, 2012
PLM0112#0599
Client: Warren Duncan Contracting
2148 Glen Helen Pkwy
Devore, CA 92407
Project: 59781 Madison Street
La Quinta, CA
(approx. 1,700 sq. ft. garage/barn structure)
On January 12, 2012 an asbestos inspection and bulk sampling was conducted at the above project
address location. Bulk samples were taken of all suspect asbestos containing building materials (ACBM)
at the request of the client named above. Bulk samples were analyzed by Scott Morrison & Associates
(DOSH •#92-0248) and Carolina Environmental, Inc. (upon request) located at: 107 New Edition Court in
Cary, NC (NVLAP Code 101768-0 and Cal. Environ. Lab. Cert. #2483) to estimate the percentage of
asbestos by volume and determine the type(s) present.
Carolina Environmental, Inc. determines percentages and type of asbestos by using EPA approved
method 600/M4-82-020: Interim Method for the Determination of Asbestos in Bulk Samples. Bulk samples
are analyzed by PLM (Polarized Light Microscopy). Asbestos is quantified using the visual arena
estimation technique and can only determine the approximate percentage of asbestos present.
After a thorough search is conducted and no asbestos is detected "none detected' will be noted in the
report. The essence of polarized light microscopy is not to emphatically determine that no asbestos is
present, merely that none was detected or, if it was, it was likely to be less than 1.0% of the sample.
When findings reveal less than or close to 1.0% asbestos contained in a sample, further analysis may be
called for on additional samples to confirm or denounce the initial findings. The California Code of
Regulations (CCR 1529) requires bulk sampling to be conducted according to the A.H.E.R.A. protocol
provisions of 40 CFR Part 763.86. The A.H.E.R.A. protocol recommends three (3) or more friable
surfacing samples from a homogenous area be collected and analyzed before any building material is
determined to be non -asbestos containing. Scott Morrison & Associates conducts asbestos inspection
surveys following the A.H.E.R.A. inspection protocol.
ASBESTOS INSPECTION BY: Scott C. Morrison, DOSH # 92-0248
The results on the following page(s) indicate that asbestos (greater than 1.0%) was detected in (01) of the
(05) samples analyzed.
(1)
Y
SCOTT MOMSON & ASSOCIATES 1855 Date Palm Drive, Ste. 3#507
P.O. Box 55329 Cathedral City, CA 92234
Riverside, CA 92517 (760)323-7743
(909)624-1665
PLM0112#0599
Note: All asbestos containing building material(s) containing greater than 1.0% asbestos by volume or
weight,' must be removed by a state certified asbe os abatement contractor prior to any demolition or
renovation of the property.
Inspector
Scott C. Morrison
Certified Asbestos Consultant
DOSH#92-0248
(2)
Type of material: interior wall felt/ black
Sample #AC -1
Location: interior W. wall
Area: throughout interior walls
Results: none detected
Friable: no
Sample #AC -2
Type of material: mudded drywall tape
Location: interior ceiling, N. side of bldg.
Area: approx. 600 sq. ft. ceiling*
*Note: Mudded drywall tape (over drywall) is also found on the interior walls located on N. side of bldg.
Friable: yes
Results: 5-7% Chrysotile asbestos
Sample #AC -3
Type of material: drywall only
Location: interior E. wall, N. side of bldg.
Area: interior ceiling & walls, N. side of bldg.
Results: none detected
Friable: no
Sample ;;#AC -4
Type of material: exterior wall stucco
Location: int. center wall & ext. N. side walls
Area: int. center wall & ext. N. side walls
Results: none detected
Friable: no
Type of material: roof shingle/ grey -black
Sample4AC-5
Location: roof above garage/ bam
Area: approx. 1,750 sq. ft.
Results: none detected
Friable: -no
Note: All asbestos containing building material(s) containing greater than 1.0% asbestos by volume or
weight,' must be removed by a state certified asbe os abatement contractor prior to any demolition or
renovation of the property.
Inspector
Scott C. Morrison
Certified Asbestos Consultant
DOSH#92-0248
(2)
State of California
Division of Occupational Safety and Health
Certified Asbestos Co-nsultant
Scott Cr-al'a Mo-rrison
Name
Certification No. 92-0248
Expires on
07/3-1112
This certification was issued by the Division of .
Occupational Safety and Health as authorized by
Sections 7180 et seq, of the Business and
Professions Code.
IB)IR,IICIKILIEYIENVI[IR,(0)NNIIENFA\IL
EnNironmental Remediation Contractor
January 23, 2012
LETTER OF COMPLETION
Stuart Duncan
Warren Duncan Contracting
2148 Glen Helen Parkway
Devore, CA 92407
Subject: Old Barn / Garage Structure
59781 Madison Street
La Quinta, CA 92253
As of January 20, 2012 BRICKLEY ENVIRONMENTAL has removed the asbestos containing
materials from the above location as outlined in BRICKLEY ENVIRONMENTAL'S proposal
#20597 dated January 23, 2012
The materials identified have been packaged and the waste was manifested and transported to
our transfer station -awaiting disposal at the appropriate waste facility. All work was completed
in accordance with federal, state, regional, and local regulations.'
Please call if you have any questions or require anything further.
Thank you,
im Brickley
Project Manager
TJB/blr
957 W. Reece Street, San Bernardino, CA 92411, Lic. No. 610414 CAUOSHA No.49
909-888-2010 800-530-3366 FAX 909-381-3433
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18. Designated Facility Owner or Operator: Certification of receipt of materials covered by the manifest except as noted in Item 17a
Printed/Typed Name Signature
Month Day Year
1
169-BLC-0 5 11977 (Rev. 9/09) GENERATOR'S/SHIPPER'S INITIAL COPY
Y AQ.MD(f
FEW
SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT
NOTIFICATION OF DEMOLITION OR ASBESTOS REMOVAL
MAIL FORM AND FEE TO SCAQMD, ASBESTOS NOTIFICATIONS, FILE # 55641, LOS ANGELES CA 90074-5641
AQMD USE ONLY SCREEN BY RECEIVED POSTMARK ENTERED BY NOTIFICATION #
COMPLETED BY COMPANY Warren Duncan Contracting PHONE 909$80.8501
Lisa Bender
DATE 1/21/12 CHECK # 14673 FEE $164.76 PROJECT # 2012-01
NOTIFICATION TYPE
ORIGINAL REVISION DATES REVISION OTHER (highlight) CANCELLATION
PROJECT TYPE
OEM LRION ORDERED RENOVATION EMERGENCY PLANNED RENO Procedure 4 Plan Procedure 5 Plan
DEMOLITION (removal) REMOVAL (annual)
SITE INFORMATION
SITE NAME Garage
SITE ADDRESS CROSS STREET
59781 Madison St
CITY La Quinta STATE Ca ZIP COUNTY Riverside
DESCRIBE WORK AND LOCATION Demo
BUILDING SIZE (SQ FT) NUMBER OF FLOORS 1 BUILDING AGE (YEARS) 22 NUMBER OF DWELLING UNITS
BLDG PRIOR 1 PRESENT USE
COMMERCIAL HOSPITAL INDUSTRIAL other OFFICE PUBLIC BLDG. HOUSE SCHOOL SHIP UNIVICOLLEGE
SITE OWNER Anthony Pauletto ADDRESS 662 W Grand Ave
CITY Chicago STATE II ZIP 60654 CONTACT Anthony PHONE
REQUIRED BUILDING
INFORMATION
ASBESTOS YES NO
PRESENT?
'ASBESTOS YES NO
SURVEY?
ASBESTOS YES NO
REMOVED?
BUILDING TO BE YES NO
DEMOLISHED?
PROJECT DATES
START 2/4/12 END 2/9/12 WORK SHIFT jday, swing, night)
'ASBESTOS AMOUNT TO BE REMOVED -
(in square feet)
FRIABLE
CLASS I
CLASS II
TOTAL AMOUNT (add row)
`ASBESTOS REMOVAL FROM
SURFACES PIPES COMPONENTS
*AMOUNT OF EACH TYPE OF ASBESTOS
(in square feet)
ACOUSTIC C LING
NOL M INSULATION
FIRE PROOFING
DUCTING
STUCCO
MASTIC
FLOOR TILES (VAT)
tDRY WALL
PLASTER
TRANSITE
ROOFING
OTHER (describe)
CONTRACTOR INFORMATION
CSLB LICENSE # OSHA REG # AQMD ID #
NAME ADDRESS
CITY STATE ZIP SITE SUPVR PHONE
WASTE TRANSPORTER #1
LANDFILL
ADDRESS
ADDRESS
x Not required for demolition notifications ' asbestos surveys are required prior to Demolition and Renovation.
Forms, instructions, and the Rule 1403 can be obtained from AQMD web site http://www.agmd.gov Page 1 of 2
SCAQMD NOTIFICATION OF DEMOLITION OR ASBESTOS REMOVAL
MAIL FORM AND FEE TO SCAQMD, ASBESTOS NOTIFICATIONS, FILE # 55641, LOS ANGELES CA 90074-5641
WASTE TRANSPORTER #2
' WASTE STORAGE SITE
ADDRESS
ADDRESS
CITY STATE ZIP
CITY STATE ZIP
*CONTROLS: DESCRIBE WORK PRACTICES AND CONTROLS TO BE USED AT THE RENOVATION AND DEMOLITION SITE. Procedure # 1, 2, 3, 4, 5 or Other.
For asbestos removals circle the combination of Rule 1403 procedures used. Procedure 4 and 5 submit plans for AQMD prior approval (See procedure 4/5 guidelines)
ASBESTOS DETECTION PROCEDURE: Circle the procedures and analytical methods used to determine the presence of asbestos in the building. Survey, Bulk
Sampling, Inspection, 'PLM, PCM, TEM, Assumed as Asbestos-PACM, Describe Other (See survey guidelines checklist):
FOR DEMOLITIONS GIVE THE COMPANY NAME AND DATES OF THE ASBESTOS REMOVAL: Brickley 1/20/12
FOR ORDERED DEMOLITION SEND A COPY OF THE ORDER AND GIVE THE AGENCY NAME & PHONE #
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 (Disturbed /damaged asbestos requires a procedure 5 plan approval priorto clean-up):
EXPLAIN HOW THE EVENT WOULD CAUSE UNSAFE CONDITIONS, EQUIPMENT DAMAGE OR UNREASONABLE FINANCIAL BURDEN:
CONTINGENCY PLAN: DESCRIBE ACTIONS TO BE FOLLOWED IF UNEXPECTED ASBESTOS IS FOUND DURING DEMOLITION OR ASBESTOS MATERIAL BECOME
DISTURBED, CRUMBLED, PULVERIZED, OR REDUCED TO POWDER. (Disturbed /damaged asbestos requires a procedure 5 plan approval prior to clean-up):
' TRAINING CERTIFICATION: I certify that an individual trained in the provisions of regulation AQMD Rule 1403 and NESHAP will be on site during the removal and
evidence that the required training has been accomplished by this person will be available for inspection during normal business hours.
Company Name Print name of owner/operator Signature of owner/operator Tittle of owner/operator Date
Warren Duncan Contracttng Lisa Bender Office Manager /
1- 6, eo
INFORMATION CERTIFICATION: I certify that the above information is correct and I have enclosed any required attachments.
Company Name Print name of Signature of owner/operator Tittle of owner/operator Date
owner/operator -7
Office Manager
Warren Duncan Contracting
Lisa Bender [
Notifications can not be accepted without the required fee (Rule 301 . Asbestos removals of less than 100 square feet are exempt from notification and fees.
Please make checks payable to 'SCAQMD". Fees are per notification, not refundable, and vary according to the project size. Fees are as follows:
PROJECT SIZE in square feet DEMOLITION OR REMOVAL
ADDITIONAL SERVICE CHARGES
1,000 or less $ 53.89
Special Handling Fee — $ 53.89
1,001 to 5,000 $ 164.76
Revision to Notification- - $ 53.89
5,001 to 10,000 $ 385.65
Returned Check Fee — - $ 25.00
10,001 to 50,000 $ 604.73
Planned Renovation — - $ 604.73
MAIL FORM AND FEE TO: SCAQMD, ASBESTOS NOTIFICATIONS, FILE # 55641, LOS ANGELES CA 90074-5641 Pg 2 of 2
FORMS, INSTRUCTIONS, AND THE RULE 1403 CAN BE OBTAINED FROM AQMD WEB SITE AT HTTP://WWW.AQMD.GOV
SCAQMD is located at 21865 Copley Drive, Diamond Bar, CA 91765-4182 PHONE: (909) 396-2336 FAX: (909)396-3342 REV20110615
50,001 to 100,000 – $ 876.40 ------- Procedure 4 or 5 Plan—$ 604.73
00 001 or more ----- $1,460.66 -- ----- Expedited 4 or 5 Plan ...... $ 302,36
ATTENTION: Keep a copy of your notification. State law requires that you provide a copy of the demolition notification to Building and Safety before issuance of a
demolition permit. For questions call 909-396-2336. Please mail the form and fee to AQMD. Mailing saves time, money and reduces traffic and air pollution
MAIL FORM AND FEE TO: SCAQMD, ASBESTOS NOTIFICATIONS, FILE # 55641, LOS ANGELES CA 90074.5641
FORMS, INSTRUCTIONS, AND THE RULE 1403 CAN BE OBTAINED FROM AQMD WEB SITE AT HTTP•//WW W.AQMD.GOV
SCAQMD is located at 21865 Copley Drive, Diamond Bar, CA 91765-4182 PHONE: (909) 396-2336 FAX: (909) 396-3342
Pg2of2
REV20110615
Warren Duncan Contracting
2148 Glen IME08 fad WMMMQ?iment District
512 - Permits
I
1/21/2012
L
14673
164.76
Rin #
City of La Quinta
Building 8E Safety Division
P.O. Box 1SO4, 7849S Calle Tampico
La Quints, CA 922S3 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
'
Project Address: S
"%"
Owner's Name:
A. P. Number: — Cy?0 _ U` p
Address:
Legal Description:
City, ST, Zip;
Contractor:
11 1 JPA JiOI
Ttieponc:
Project Description:
Address:
City, ST, Zip: n
KATelephone: 7 -U — eayl
U 44
State Lic. # : S , City Lic. #.:
1 N
Arch., Engr., Designer: '
Address:
' t
City, ST, Zip:
Telephone: Construction Type: Occupancy:
State Lic. #: «:s'su Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person: CCl Sq. Ft_: ` ,r. #Stories: # Units:
Telephone # of Contact Person: 10q — Estimated Value Of Project:
APPLICANT: DO NOT WRITE BELOW THIS UNE
#
Submittal
Req'd
Rec'd
TRACKING
PERMU FEES
Plan Sets
Plan Cheek submitted
Item Amount
Structural Calcs.
Reviewed, ready for corrections
Plan CheekDeposit
Truss Cales.
Called Contact Person
Pian Cheek Balance
Title 24 Cates.
Plans picked up
Coaatrvction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2" Review, ready for correctio
l S
rival
Sabcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
INHOUSE:-
Review, ready for corrccdonslrssne
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees