DEMO (0304-064)LICENSED CONTRACTOR DECLARATION
U) I hereby 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
WProfessionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
r• LO
wCi C21 `._.� r l 043131 J2(
oZ D"a'te U•� d() �_ Signature of Contractor—s-�
�LD0�
I-' � OWNER -BUILDER DECLARATION
W W 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).
cr)() I am exempt under Section
110B&P.C. for this reason
N Date Signature of Owner
ON
rn
d Q WORKER'S COMPENSATION DECLARATION
o cc I hereby affirm under penalty of perjury one of the following declarations:
Lo O () 1 have and will maintain a certificate of consent to self -insure for workers'
X Lu �L compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q () () I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d F- permit is issued. My workers' compensation insurance carrier & policy no. are:
C6 ZCarier STATE FUM),Policy No. 0402611653.2003
ao �
J (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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code„ -Shall forthwith comply with those provisions..
Date Applicant ,I
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 upoh'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, indemnity
& 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 purposes.
,i�� �,�/l �j
� /Signature (Owner/Agent) Date 1�2
„ - �. •
BUILDING PERMIT PERMIT ti
0304-064
DATE VALUATION LO TRACT
JOB SITE
APN
R •��Vve
ADDRESS„faP 16eO�iG �
_
OWNER
CONTRACTOR/DESIGNER/EN (NEER
13 LP ,PW5ASSADO tWAY
85-155 AVE 54
SALT LA= C13.. 1JT 84018
TMRMAI. C.A. 92274
0760)345-4746 mul 19
USE OF PERMIT
DEMOMInOX
S.)EMID CHIP 7200 SY1•iBA.N130N1? D HOUSM & CJUEST HOUSE, PER :4.1°PTta VEE
REQU14(1MENT0
F.vrFA1WJ..TJ) 008.170F Ct7.IV9'fRi7•G°TION
:l.l3tD
TIER.M ICT 16":kT. RUWA4ARY
DEMOLITION M1~ 101.00.G 473.000 185,00
r ,
Q �
D
APR 0 7.10 03
CITY OF LA QUINTA
FINANCE DEPT.
' s
kM--rb�fALCC71+1.8IRT3MON.FlNT3PT” CWCK
LESSP5�4'�Pt� JD 2'�k, S
1X)TAX T'L'R,1L13'iFi;"r. DWE 140W
v.,tDO
RECEIPT
DATE
41- -7 c �
BY
)� 4
DATE F ALED
�3
INSPE T
. .
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
OX 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 I I
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:
f 12 03
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)
r '
15 56 CfiPRF3 ESCI UW 4 1760 991968 NO. 071 001
. 03252003 -
• eaaRtl>Eww IH$TRualtoM� TOs ,:._ . ...
6733 BIb¢Kton Avenue Eamw No.: 16263-D Data: 01/17/2003
Wvwulde, CA 05006 ENMW OMP"; DebiBgloy
. ffW�1 e e mo% 7784370 Flus i $001779.190
scroo
MMo
WNW
CashCult to
Deposit
to Follow tlurdugh Eelaow I -
Total CoWW"Ation
addition to the sutra o which has been
Oa or before Match 31. 2003, Buyer will hand y� �to �
deposited with escrow to corql= A tubal sonaidaation ofimmom.
Buyer to hand you any additional Aitch x,td instruments neceMyfor you to comply with ili trttctiona herein. Obtain an
ALTA LOAN Standard Coverage Form JOHOY of Tide Insttra>iae from First American Title blaurartoo Cantpe¢ly with
to standard maplions and provisions, This policy is to have liability for an amount not to eaeW
The policy is to be issued on real property to the County of ltiver6ide, State of Ca , as follows:
Legal description attached hereto as exhit it" A'
Macao: Froptstry Address: .
6099s Monroe SIMA
Thermal, Ca 92774 "APN 764.270-015 & AFN 764.280.014
The Ode policy is to show the tide to UW) rtoperty to be vested in:
Monroe Dates, Lirtlited Liabllir' CMtAWY .
- � +6J!1CUMBRAIr10E$lEXCRPTIO[Ve
The policy is to be free of encttrnbranees oxcept as follows:
1, General W Special Taxes and S-ecial Dlatriot Levies not due or delinquent; this will include the liar Of
supplemental taxes, if any, assass®d 1 ttlrluent to Chapter 498,1983 Statutes of the State of California. withoutor law
2. Covettalltx, conditions, �striettona,(ri clu of way ends Of 0"' �s Par p blres�ub'l�e, diatrtetap wacompanies,
tight of SWI4 o entry),
alleys, and streets
t
La slWordam with inamoons t m the attaolted pages, you are to Oust Of prorate taus to close of escrow.
ttAQl PAnY YlfdI1HO 7xttil rH/rAtlMr{0111 HA! i tiYAM 7rte 4PPlrrekAl e6CItOW tptlPrrI0N1 Aero w1rR1fC7tMN9 011 INi AtTAp110 tum AHO
Hepr aY AVIfIOY!!s. AMnI}Ta AND AORW 70,6° VWNP THIRUIT AS THOUNII THI ATTWIP PAOIA APPe/ OD 0Y67r tri AieHATltnii THE
pAUMHaRN. ALSOAOWOWIYYit1HAYINDPKEIYWAMPV0yTHlaeIN/7ROMtrON&
Th, ttr Ovido"a, oondiAtma and inatrucAoto, end (Noce on the ntmehed pggo: am hmeby approved tom atsooud is
(O MUCnoa PR0M$EjUjV tbrtgOlvB ob p documm h o411ed lDt on rt0 ptn W eovse title to be ahowo m obtrva arttrtl You
wtbotiaxd m
d dir ontircly and an o>�mod Mtty rax. 1 w,11 hand i0u careoaaaty ar faarow tdtolgt f tray leWW" foot, ormlae for
detivir nmeA yoo bald it hrn OR" to be applied M do act ibrt8 Above wi1Mn the time as above provided. FAY o d to bmme, eoaosmemna.
,vide„ ea of tide as Celled ft V&agr ar trot lhi. eecx W b aooemtw W, oacept Aweo the boYm >Pad to p% You etc l e al0 m,dwive MY
,yet, and 4 by lieu of ftwd, ineWN PrIpoyt�t p Maldaa, if my, without my tWtha opFro"i), to ahoy Aso asvatted (W. F'Y oanlmtnra� Teotu4r trot l P dad
6Uytlels
Monroe D e, L ngited Liability Company
B)r
1)
6.Ade blgnpture
J. Rory O'Rourke, TM"C
Received 13y:
aro SEB ADDITIONAL INf,TR IC Y tH ► 5 � ORFONA11TO A14DMON:t ( OM9Mo OEt1b�t479
EAPNlR pAWIOYb RlC, Ill L ICBM
pato t a[e
i0 39dd (1109Nf1S-1ti0 896Z66E09L
E1::LZ 600Z/5Z/E0
?!3/252003' '15:56 CRPRE9 ESCROW -),17603591968 NO•071 002
[SCROW INOTRl1MONS TOC
pre8789 proakion Avenue EscrowNo.: 16163 -D " Dam: o1117td�3 Mverawe, CA 92505 stow o,3amrr. Dabi Bigley_
7794370 . Pax 909) 77i•lal0
�S�rd1N cbanav�
.INSTRUCTIONS
MSTRUCMNS/COIJN*RSISUPPLFJAE.NTSIADI)ENDUM: These escrow iustnKdOns'sre cx=iad for t)s a
purpose of ettabWlg the Escrow HW]kr u oomplete this husaotiou, and are not inun&A to att=end, modify, sup
m any way cbmW. the Putehose Agratrout, ESCROW NOl ERS RBSPONSIBIUTIKS AU L M.= 7V 7WE
liEJfS'SET OUT IN THISINSTRUG7::ON:
TO THE EXT24T THESE INSTRUCTIONS ARE INCONSISTENT OR CONFLICT Wf1H THE PURC1iASE,
AGREEMENT, THESE INSTRl7CTIOVS WILL
COMM AS TO TIiE' AD IBS AND OI
ESCROW HOLDER ONLY, WC -.W pLDE)1 SHALL B$ N
.r.,.o ^" e+ennnYU unr ave
ZO 39Vd
A. All ocher coals in oonpecdou with t)as escrow will be paid by buyor and sellar as customsry. Second half 2002.03
taxes shall be paid through escrow M.4 prorated accordingly.
B. THE 1 NDERBtGNED BUYER AND SELLER ACKNOWLEDGES HA'L'ING RMIVED THE
p)tET.DWARY TITLE REPOR r 1SSUl3;D BY First American 71Ue In3urance CMPDY, Rtb7£Y#ENC1$D
AS 01pi>3R N0. - 817374. TITS PRELINMARY TITLE REPORT ANA THE PLAT MAP HAVE
CAREFULLY BEEN FIVIEWED BY THE MERSIGNBD AND An ACCEPTED IN TUM
EN'M'ITY, WITH TOR UNDRIISTAND'NG TEAT ITEM a WILL BE AE XTED AT C[ M. AND 2190 .
i1A1.p' TAXES WILL HE PAD) BY ULf." AT. CLOSE OF 11,SCROW.
C, AS pEQlmt6I1 BY LAW WE ARE SUPTUAS Vr' OUR ESCROW WSCRUCTYONs AS TO THE
FOUAWING:
CALM ORN)A REV17MM : AND TAXATION CODE SEC IONS 18662 AND 18668 PLACE SPF,=
RBQUIREM TS FOR TAX RM-ORTINa AND yWnMJOLDING ON BUYER WIMN (l) the solh`ng Price's
greater than $100,000.00, and (2) the home being sold was not the sellers pdmsry 'residence in Csla�ae
evidenced by the Withholding Exettptioa Certificate, OR the funds ftom the transaction pre to be die AMd
to a financial intermediary of the Salla, THE WITHHOLD94G RATE IS THRID AND onc-thud per cent (3 & 1130
OF TM SELLING PRICE AS DFa'INED IN THE STATUTE.
Sauer is aware that due to Traveblse Tax Board changes whkb become effective JaOaary 1; 30039 it salter
=met $wept under penalty of perjury that subject property gnalluea as their principal residence, or swear
that they are a Tax Ixempt Non.IndlAdual, or othtrwlse ercenlpt by reason of depositing one of the following
hilly execated. forms 993.0 ,593-W or 593-L Eeetow hoidor if Required by the Put! iia tax board to
Withhold and pay to the frantblar, ta>z board 3 & 1/3% oP the total sales price,
The buyer raIq become subject to p enalry jar failure to withhold an amount cemal to the greater Qf 10% of the amount -
required to 8e withhold or five hun fred dollars ($5.00.00).
F1DERAL LAW,
WTRNAL REVMU COD'S SECTION 1455 PLACES SPECIAL R>iQU1REl iC3 FOR TAX REPORTINGANO-
AND W)1Ti1lOLDD* ON PAR1196 TO AREAL ESTATE TRANSACTION -WHERE THE sFiLLER IS A NO-
AND
AINN, A NON -D01 ABSTiC CORPORATION OR PARTNERSHIP, A DOMfrSTIC CORPORATION
OR PARTNERSID CONTRoUM 8Y NON-RESIDIRM OR, NON-RESIDENT, CORPORATION OR
pAR']1�I'A.SHII'S• .
W1T1I RESPECT.TO BOTIi TH1I STATE LAW AND FMBRAL LAW RBFwun, TO ABOVE THE PARTIES
TO REHIS TRANSACTION ARE g> IOCING AN AMM.VS, ACCOUNTANT'S OR •OTHTll1 TAX
Sellers Stratum
auyers819Tute .
11Doses, Limited Liability Com �aay
7, Rory a'Rrnnke; TN9toe
------------
Rocdved By:
�•• SES ADDITIONAL I48TRUCTIONS ATTACH0G'flMT0 AND MAM A PART IMSOF
t nch gjthe above Signed a ore's he has read tA¢l0►atC°iHe,tnsnuctty»s and undarstalub a»d agneas to them•
"jc2ct4
Q'10ONf1S—id0 89G T66609L
A
9
ET:Li C00Z/5Z/E0
W/25/20W .15:56. CRPREE ESCROW i.17fiGI�991968 NO -071 D03
ESCROW IN5TRYCTION6 Too
a preB 679$ Smekton Avenue sdemwNO.: 16263 -D Date: 02/1112003
LY Mveroido, CA 98906 PA=wMor. Debi ftlOr
(VOW "84379 f;;W (OW 770 -IM
(Cowhiped)
SPI?CNALISTS OPINION COT U.RNING THE EFFECT OF THESE LAWS, . THE PARTIES TO THIS
TRANSACTION ARE NOT ACt'ING OR RUYINO'ON ANY STATEMENTS MADE OR OMIT= BY THE
ESCROW OFFICER, TITL13 OFFICK OR OTHER CLOSINO OFFICER WITH RESPECT TO TAX
REPORIUVOOR WMiHOLDIKG REQUIREMENTS,
D. IN LTO; EVENT A CONFLICT )R CONTROVERSY SHOULD ARISE. ESCROW HOLDER RESERVHS THE
RIGHT TO COLLECT A NO), THLY HANDLING CHARGE OF 525.00 PER MONTH FROM FUNDS ON
DEPOW, IF TIRE CONFLICT OR CONTROVERSY IS NOT RESOLVED TO TTIE SATISFACTION OF
ESCROW HOLDER WFTHIN 90 DAYS FROM THE RECITER) CASINO DATE,
F. THE FOLLOWING ITEMS ARI; BEING SET OUT AT THE REQUEST OF 1% PARTIES HEREIN AND DO
NOT CONSTTfUTE INSTRUCT (ONS TO ESCROW HOLDER. THE FOLLOWINO 16 A MEMORANA ONLY,
ESCROW HOLM IS TO HAV ? NO LIABILITY OR RESPONSIBILITY FOR THE FOLLOWWO E%IrbRS:
I. NO FIRE AMOR L HAZARD INSURANCE IS TO BE -OBTAINED IN CONNECTION WITH THIS
ESCROW. BUMS ASS(DIES ALL RBSPONSIBUZYFOR T11EM FAILURE TO OBTAIN INSURANCE
THROUGH TO ESCROW.
2. ESCROW HOLDER IS TO HAVE NO CONCERN AND OR USPONSIBTC.ITY FOR THE TRAN$FBR OF
SEC[IRTTY DEPOSIT ANWOR PRORATION OF RENTS.
3. NO FUNDS SHALL: BE P3,SASRD PRIOR TO CLOSE OF ESCROW. FUNDS SHALL BE DISBURSED
AT CLOSE PER SEPARATE INSTRUCTIONPEPOSITED BY THE SELLER,
CY NO ICE:
THE UNDERSIGNED ACKNOWLEDGE, REC>PT OF A COPY OF THE PRIVACY NOTIC ISSUED BY CAPREE
ESCROW.
B=G INE" UC%TQIYBI
ESCROW HOLDER IS AUTHORL7i'.D TO DISBURSE ALL OR ANY PORTION OF FUNDS BY AQ os OF WIRE.
OR ELECTRONIC TRANSFER IN 71 B EVENT SUCH TRANSFER BECOMES NECESSARY OR CONVENIENT
FOR THE CONSUMMATION OF n a& ESCROW.
IrACS1A�I.R BI($V,A�7JRRS- - '
IN THE EVENT PARTIES UTILIZE "FAC'SD&E" TRANSMISSION OF SIGNATURES ON ANY INSTRUCTIONS
OR DOCUMENTS REQUIRED FGA THE CLOSE OF IRIS ESCROW, THE.PARTRES A07HORIZE ESCROW
HOLDER TO ACCEPT SAME AND TO RELY UPON SUCH DOCUMENTS AS IF THEY BORE ORIGINAL.
SIGNATURES.
Cepree Emow, Inc. CONDI 118' BUSMSS BY • AUT801111TY OF THE I)rkPARTMVff OF
CORpop ATIOn STATE OF CA NORMA, A.Q.C. UCENSIG N MBER 9631479.
8uyete Blgneture ' 8efiers tR(gnaturo
Monm Does, Limited Liability Cam imy
I. Rory O'Rouft, Trustee .
Received BY:
•�� SEE AI)DMONAL DiS'T'RUCTIONS ATTACIIED HBNLB'Pb AND AdAM A PART HMMF "'•
Earp of 8ie shave rigr+dA stctcs he ho rddd the jordpoing ►nsirudRana and unddrrtpnde and gr6010 $Aenl.
• Jluce 3 ota
60 39dd _ Q'109Nf1S-1d0 896TS66094
ET:LZ E00Z/5Z/E0
J
L
64 - 27
IN15 Me WAS PREPARED FOR ASSESSMENT PURPOSES ONLY. NO LIABILITY
SEC.34 T. 6S.
R. 7E
T.R.A.
058-085
Is ASSUMED FOR THE ACCURACY OF THE DATA SHOWN. ASSESSOR'S PARCEL
MAY NOT COMPLY WITH LOCAL LOT—SPLIT OR BUILDING SITE ORDINANCES.
'058-041
761-22
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28
27
M8 42-0 f
1 4
21
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35
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PAR i
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PAR 2
,
9.19 AC NT
10.35 AC G_R
9.82 ACM
10.24 AC GR
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IHGLE 40O .
II.—
829
II PAR
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I
•112.84 AC MR
.-
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9.63 AC NT
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$
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140.67 AC MIL
-
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EX
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18.33 AC MIL
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DATA: GLO PI,Af
RS 51 52
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OR 24 4-65
°
MAY 1 0 2031
ASSESSOR'S NAP OK764 PG.27
PM 89/69-70 PARCEL MAP N0. 13971
wr uLOAvnri 2�Auc:A
e
Riverside County, Calif. ('it
Apr 2001
9u,v9.:e
Cityo La
Quinta
Developers PM -10 Approval Form
Prior to the issuance of a Demolition Permit for the project listed below, Public Works
approval must be obtained. Please return this form to the Building and Safet)l Department
only after approval. ,
Project Address:
0 9S- 01a/7rd-e sir
Scope Of Work: � � `� 4el?
waw 61( ov_� C '
VA
• AdcquA w&kr for l oad d s i
• TQrp an I rxads Iea��n9 si or wed -b eli r� nak �tu.5-E
N Yo
Public Works Department Approval is Hereby granted:
7 03
John Freeland,�gineer Date
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 Lo� taM- COMPANY � �n � CI �i PHONE {fir
DATE `�" ' ` 164 ) -S$"
Z� �� j CHECK # FEE $ PROJECT #
NOTIFICATION TYPE ORIGINAL REVISION DATES REVISION OTHER (highlight) CANCELLATION
PROJECT TYPE CIE ORDERED DEMOLITION RENOVATION (removal) EMERGENCY REMOVAL PLANNED RENO (annual)
SITE INFORMATION SITE NAME
SITE ADDRESS_ q qs- CROSS STREET
CITY / ' STATE, ZIP Z.L7 COUNTY
DESCRIBE WORK AND LOCATION �� S
w
BUILDING SIZE (SQ FT) a NUMBER OF FLOORS BUILDING AGE (YEARS)f p le NUMBER OF DWELLING UNITS
BLDG PRIOR 1 PRESENT USE COMMERCIAL HOSPITAL INDUSTRIAL Other OFFICE PUBLIC BLDG. HUSE SCHOOL SHIP UNN/COLLEGE
SITE OWNERrb -11 645 LL ADDRESS
3 7 fim b6tsso olor i�
CITY �A,( . l f j, STATE ZIP CONTACT h �]
T" PHONE�I. 3_'rT �'
REQUIRED BUILDING ASBESTOS YES . NO ASBESTOS YES NO ASBESTOS YES NO BUILDING TO BE ES N0
INFORMATION PRESENT? SURVEY? ' REMOVED? DEMOLISHED?
PROJECT DATES START o -S END 3 D a3 WORK SHI (day, wing, night)
r U .
ASBESTOS,AMOUNT TO BE FRIABLE CLASS I:,
REMOVkD (in square feet) CLASS II TOTAL AMOUNT (add row)
ASBESTOS REMOVAL FROM SURFACES PIPES COMPONENTS
AMOUNT OF EACH TYPE OF r:.. ACOUSTIC CEILING LINOLEUM INSULATION' FIREPROOFING DUCTING STUCCO MASTIC
ASBESTOS (in square feet) _..
FLOOR TILES (VAT) DRYWALL PLASTER TRANSITE ROOFING OTHER
(describe)
CONTRACTOR INFORMATION CSLB LICENSE # dao_)ff OSHA REG # AQMD ID #
NAME 113 i//1 ADDRESSd�(J 1109
CITYCITY
STATE Cj� ZIP C� U SITE SUPVR
" 1 I 2,7-77 tJt/�►/ILS C, PHONE 3q
WASTE TRANSPORTER #1 LANDFILL 7
ADDRESS
ADDRESS
CITY EST7ATE��Zlp CITY STATE ZIPF
s Asb", g surveys are required prior to Demolition and Renovation
SCAQMD NOTIFICATION OF DEMOLITION OR ASBESTOS REMOVAL
MAIL ORIGINAL 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.
SBE OS DETECTION PROCEDURE: CIRCLE THE PROCEDURES AND ANALYTICAL. METHODS USED TO DETERMINE ASBESTOS IN THE BUILDING:
Sury ulk Sampling, Inspection, PLM, PCM, TEM, Assumed as Asbestos-PACM, Describe Other.
FOR DEMOLITIONS GIVE THE COMPANYNAME AND=DATES OF THE ASBESTOS;f EMOVAL � JW.
FOR ORDERED DEMOLtTjION 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 0
EMERGENCY AND DESCRIBE THE SUDDEN, UNEXPECTED EVENT:
EXPLAIN HOW THE EVENT WOULD CAUSE UNSAFE CONDITIONS, EQUIPMENT DAMAGE OR UNREASONABLE FINANCIAL BURDEN:
CANfI ,9ENCY PLAN: DESCRIBE ACTIONS TO BE FOLLOWED IF UNEXPECTED ASBESTOS IS FOUND DURING DE (TION OR ASBESTOS MA RIAL BECOME
DISTURBED, CRUMBLED, PULVERIZED, OR REDUCED TO POWDER. 0 b �,V Pj / i 4� l a4
TRAINING CERTIFICATION: Pcertify that an individual.(rained 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 beailable for i spection during normal business hours.
dw—�Signatu e f r TittlL�L9ner/�operat Date y/(
CMpana dame of ownerloper—ator nerlo
INFORMATION CERTIFICATION: I certify that the above information is correct a I )ha�v,Ve ed any required attachments.
�Q D5
�
� Gam°"1Tittle=Dat-
6rianyN ImSignatu erloper Tittle = p
P Pnnt n e of owner/operator
Notifications can not be accepted without the required fee (AQMD 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:
DEMOLITION OR ASBESTOS REMOVAL PROCEDURE,4 OR 5 PLAN $ 321.56
FROM 1dd TO 1,000 SQUARE FEET $ 28.66 SPECIAL HANDLING FEE $ 27.35
FROM 1,001 TO 5,000 SQUARE FEET REVISION OF NOTIFICATION $11.59
FROM 5,001 TO 10,000 SQUARE FEET 05.7 RETURNED CHECK CHARGE $28.43
MORE THAN 10,000 SQUARE FEET $321.56 CANCELLATION OF NOTIFICATION $ 0.0
DEMOLITION OF LESS THAN 100 SQ FT .$28.66 ASBESTOS REMOVAL AT owner- $ 28.66
occupied, single -unit dwelling
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 o
demolition permit. For questions call 909-396-2336. For your convenience please mail the form and fee and do not hand carry to AOMD.
MAIL FORM AND FEE TO: SCAQMD, ASBESTOS NOTIFICATIONS, FILE # 55641, LOS ANGELES CA 90074-5641 Page 2 a
TELEPHONE: (909) 396-2336 FAX: (909) 396.3342 Form REV 06072002
FORMS, INSTRUCTIONS, AND THE RULE 1403 CAN BE OBTAINED FROM AQMD WEB SITE AT HTTP://WWW.AOMD.GOV
SCAQMD Is located at 21865 E. Copley Drive, Diamond Bar, CA 91765.4182 (909) 396-2000
y
CITY OF LA O NI TA L
EMERY LAND CLEARING JUN 2 5 RECD
P.O. BOX 1009
THERMAL, CA 92274-1009 BUILD111;
7601391-5840 FAX. • 7601391-5839
LIC. #600283
JUNE 23 2003
CITY -OF LA QUINTA
78-495 ,CALL- E TAMPICO
LA QUINTA LLCA- 92253 .
ATTN: MR. DANIEL CRAWFORD .
FAX: 760/777-7011
760/777-7027
SUBJ: _DEMOLITION
=60=995 MONROE:-STREET.`
LA QUINTA, CA
DEAR MR. CRAWFORD,
IN REFERENCE TO OUR CONVERSATION ON THE ABOVE MENTIONED DEMOLITION
PROJECT, THIS LETTER IS TO CONFIRM OUR DEMOLITION OF 2 HOUSES, REMOVAL AND
DISPOSAL OF CONCRETE LINED LAKE AND REMOVAL OF SEPTIC TANK'S.
EMERY LAND CLEARING DID REMOVE SEPTIC TANKS FROM ABOVE PROPERTY, THEY
WHERE PUMPED AND REMOVED, ATTACHED ARE ALL THE DUMP TICKETS AND PUMP
TICKET FROM Al CESSPOOLS.
IF YOU HAVE ANY FURTHER QUESTIONS, PLEASE -FEEL FREETO CALL MEAT THE ABOVE
PHONE NUMBER.
THANK YOU FOR YOUR TIME IN THIS MATTER.
SIN'EREL ,
EMERY L CLE^ING
a
e re « "a i � , :� / .•,i is � t 3 -t +
z 9k
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'Setv
cfN
J : w P.O. Box`58o188 North P! �nC' i>
alm Springs, CA 92258 JOB
E INVOICE
:R. `Since 1959' a
r _ r(760) 329,
.6875 (76)251-3405 t i
State I,lCr #265214.• CustomerOrrlerNoi� 'Date:Orde ty ��
s vv" al cesspool coII
"r,
4 I'.� � r ^" •"� % d3: r
S . \ �. rj OrdaraTakeni8 Data pr
ornlsed
ADDRESS 1M 2-Y� F CO et,C't'Cl y r PHO( E
t1 r
's CHNICIAN
ADDRESS V
0 13q5
r ... - rl _
z�Y�C Ynr:. f VL
f `3 SERVICE PUMP SEPTIC TAN T Pic- �Oc Mo' Z�t�
a , REQUESTED C1 PUMPSEEPACE P1TATITS�R TANK BE ETk.DUGUP7
{,
No PMT'ON SITE
. } t ; ' •{ - Yes,❑ OFF7cNB-I Lbc. -
I QUANT.
r DESCRIPTION OF,
4 i
e ' PRICE
j Pumping Fee per 1000 Gallons (or &aclion) (uNr
■ - � Waste ]]lScharge Fee r 1000
.41
YVI
�• � • Out of.4rea Fee. *, ,,� � r� .� ���„���� x _
L x tc CIH
L
'r� s3 1 / � ' s u .t i '� •
y
if%m ❑'THE LEACHINGSYSIEMHASFAILED. r
. .. t] THERE IS AN OBSTRUCTION''UPSTREA
- M" OF THE SEPTIC TANK ` >
r
. F 7t vnD he : nates to contact a fine dCompany.'t •
eanmg `
❑ WE RECOMAgEND MAINTENANCE PUMPMG OF T 3
- 0. YEAR OTHER YEAR 2-3 YEARS' SEPTIC,TANK EVERY r {
Torano b
- uilt up solids ,1hg wM increase the life ofyout lea r ! J. .
di4systan
' O THIS PUMPING WILL
t. t t a: x � ❑ CUSTOMER'HASB PROVIDE ONL--Y TEyPO-ELLFMOTSOLVE CUSTOMERS SEPTI RAR
YL
EAgo
s C
+•'>,;;zi`xA.:Ag�a�dsd:.s.�... 3 rs:%� � _...,..c,,Eyt: }.
.TfYENAN"EXPHAtNA770N..
nr..,Kr""s�^s,c'L' �,`SPACKEPp';'f✓",�/.x', ".,� Y
•' 1 ���'`'Trr''i�`s"., sAYS.x�+SA1VlC6GN�AdRCBp"�
c r - '�"•�" ...... Ot-.._.L�RRTT Fi� LL,BE DUE ,._ae����FF�.st.:, r ���� ! rx. ';" '.�' r". x ' ° -
A FINANCE CHkRGE OF l 1I2Y PER M r r
" D ON7H,18 %PER
CHARGED ON PAST Y ,
UE ACCOUNT, OVER JO D R -WILL BE
+ IF PAYhfE7ff 13 BY CHECK
,
•
DRIVERSLICif •'{'
STATE
l hereby acknowledge the
ove
sadAa.
` r �. SIGNATI(Ac ' . agcy eompletlao of,h,e abdeserlh.� a.,._e. `. b w ..,x...a ex. '�;fc".s',..as.•x.., 7 . -
P.O. BOX 361 08516
THOUSrA;N!6 PALMS, CA 92276
1imvnirr
f
71 ?iverside County
ManagementDepartment
REDRICK STREET, MORENO.VALLEY CA 92553._,
WASTE DISPOSAL OFFICIAL RECEIPT
Site IF: 27 EDOM HILL Trans #: 057886
Customer: 1168 EMERYIANDCLEARING
Hauler: 1168 EMERY LANDCLEARING
Vehicle ID: 0000 Badge #: 009465
iicle Type: 08 Jcode: 84
fuse Type: 05 CONST/DEMOLITION WASTE - 75% OF LOAD - 3.62 Tons at $30.00
CUSTOMER COPY
wi0,
00074843
FOR CREDIT, ACCOUNTING INFO.
AND DISPOSAL SITE OPERATION
PHONE 1-909-486-3200
15:28:03
51112UU3
Gross:
18.20 S
Tare:
14.58 K
Net:
3.62
$108.50
Amt Due: $108.50
00074843
1� Riverside County
erste ManagementDepartment
FREDRICK STREET MORENO VALLEY, CA
GSA:92553
lte #: 27 EDOM HILL
Trans #:
057886
15:28:03
Customer: 1168 EMERY LANDCLEARING
Gross:
Hauler: 1168 EMERY LANDCLEARING
Tare:
Vehicle ID: 0000 Badge #: 009465
Net:
hicle Type: 08 Jcode: 84�A
Ouse Type: 05 CONST/DEMOLITION WASTE - 75%,OrsoWx
3.62., brist
.00
I;V-� t
Ilk
Amt Due:
5/l/2003
18.20 S
14.58 K
3.62
$108..50
t0,25,
W1. 3S-
$108.50
j
•�
Net:
y' Riverside County
L
Waste Management Department
$165.25
i
^0-007
5171
Amt Due:
County
J
.dverside
IV/anagement epartment
FOR CREDIT, ACCOUNTING IA
OPERA?
Hauler: 1168 EMERY LANDCLEARING,,
AND, DISPOSAL SITE
PHONE 190948E3200__
Badge #: 009465
Vehicle Type: 08
WASTE DISPOSAL OFFICIAL RECEIPT
88
C ���-
FREDRICK STREET "MORENO VALLEY,CA 92553
GSA:- I2=LC ' Site #: 27 EDOM HILL
Customer: - 168 EMERY LANDCLEARING
-Hauler: 1168. EMERY LANDCLEARING
'---.Vehicle.ID: 0000 Badge #: 009465
Vehicle`Type: 08 Jcode: 88
Refuse Type: 05 CONST/DEMOLITION WASTE - 75% OF LOAD
Trans #: - 058214
5.51 Tons at $30.00
CUSTOMER COPY
11:"Lti:Sb a�acvv.�
Gross: 20.09
Tare: 14.58 H
Net: 5.51
$165.25
Amt Due: $165.25
00075171
Gross:
Tare:
20.09
14.58
Net:
y' Riverside County
L
Waste Management Department
$165.25
14310 FREDRICK STREET, MORENO VALLEY, CA 92553
Amt Due:
Trans #: 658214
Customer: 1168 EMERY LANDCLEARING
Hauler: 1168 EMERY LANDCLEARING,,
Vehicle ID: 0000ti
Badge #: 009465
Vehicle Type: 08
Jcode:
88
C ���-
Refuse Type: 05 CONST/DEMOLITION WASTE -
7.5% OPLAOADs'
5.51- Tohs,at�. $30.0(
r \moi s}?1
11:"Lti:Sb a�acvv.�
Gross: 20.09
Tare: 14.58 H
Net: 5.51
$165.25
Amt Due: $165.25
00075171
Gross:
Tare:
20.09
14.58
Net:
5.51
L
$165.25
_I CIbr�
Amt Due:
$165.25
riverside County.
rD
'Management Department
alREDRICK,STREET MORENO VALLEY, CA 92553
l.
WA
Site Trans #-
Customer:.. 1168 EMERY LANDCLEARING
1168 EMERY LANDCLEARING
Badge #: 009465
hig e
ID: 0000
-iiiaeType: 08 Jcode: 88
00075460
FOR CREDIT, ACCOUNTING INFO
AND DISPOSAL SITE OPERATI&
DISPOSAL OFFICIAL RECEIPT PHONE 1-9094863200
efuseType: 05 CONST/DEMOLITION WASTE - 75% OF LOAD 3.29 Tons at $30.00
CUSTOMER COPY
Riverside County
Vaste ManagementDepartment. . .. . . . . . . . . . . . .
-f� 0�
3105TREET MORENO VALLEY, CA 92W
i&�: zz-tK iei1;1::,;Trans #: 058503
Customer: 1168 EMERY LANDCLEARING
Hauler: 1168 EMERY LANDCLEARING
Vehicle ID: 0000 Badge #: -009465
lehicle Type: 08 Jcode: X88 %4
�5
, e�,
"
lefuse Type: 05 CONST/DEMOLITION WASTE 29 Tone -4h �rt
- 75,%QF(Q5AD,$360
tj
,j
15:20:34
Gross:
Tare:
5i5i2003
17.87 S
14.58 K
Net:
3.29
$98.75
Amt Due:
$98.75
00075460
Gross:
Tare:
17.87 S
14.58 K
Net:
3.29
$98.75
Amt Due:
$98.75
,?iverside County
Management Department
� '�ar.5?JiSrai96 k f
FREDRICK STREET, MORENO VALLEY, CA 92553
Site #: 27 EDOM HILL
GSA: 22=ER
Customer: 1168 EMERY LANDCLEARING
Hauler: 1168 EMERY LANDCLEARING
Vehicle ID: 0000
Badge #: 009465
ehicle Type: 08
Jcode: 88
refuse Type: 05 CONST/DEMOLITION WASTE -
75% OF LOAD •
LM—
WASTE
00075357
OFFICIAL RECEIPT
TT10:05:25
Gross:
Tare".
Net:
3.12 Tons at' $30.00
CUSTOMER COPY
Amt Due:
FOR CREDIT, ACCOUNTING INFO
AND DISPOSAL SITE OPERATIOP
PHONE 1.909-486-3200
17.70 S
14.58 K
3.12
$93.50
$93.50
00075357
Riverside County
Afaste Management Department k
-
310 FREDRICK STREET, MORENO VALLEY, CA 92553 rdns ; 5;25 5/5/2003
13T
ie
1168 EMERY LANDCLEARING Gross: 17.70 S
Hauler: 1168 EMERY LANDCLEARING ,,`5 Tare: 14.58 K
Vehicle ID: 0000 Badge #: 009465 f �� s ,-> tis Net: 3.12
Jcode: 88
Vehicle Type: OSS
�. --- r 3.12 To;
at `$30 00 $93.50
Refuse Type: 05 CONST/DEMOLITION WASTE 75%tOF�L OAD� s ,, i" Q ,1e
}
$93.50
Amt Due:
ite of California California Integrated Waste Management Board
NMB -62 (10/94), °` 8800 Cal Center Drive' •Sacramento;, CA 95826,
WASTE TIRE HAULER MANIFEST
iTRUCTIONS ARE ON REVERSE SIDE OF FORM
RT T.TOj BE COMPLETED BY ,REPRESENTATIVE OF TIRE DEALER OR WASTE TIRE GENERATOR :.
ire Dealer/,Generator.'(include Board of Equalization Tire.Recycling Fee Account Number"):�V
ami & Address /� E it -y, j
�Tfi��ri,;C ,g�a7y;
' -ounty jvk,f S c-te (Area Code) Telephone Number
late of -Pickup. (Month/Day/Year) .
Vhole Tires:in,this Shipment,., OR->• -,Volume of Tires -in this Shipment Weight of,Tires in'This`Shipment
(cu
bic,'yards) OR (Circle One) pounds, tons
Aj
certify that the: information provided above. is true *and correct ` I4certify that.Part 2(a) :and Part 3(a) were completed at the tirne'of, this certification I
n aware that falsification of this manifest may result 'in cavilil Ren qs:or-administrative civil penalties'as described in Rublic Resources;Code Section
2962 (a) and (b): (See reverse side of this.form),"
Waste Tire,Dealei/Generator Representative Signatur
Date 3e - 4 3 printed Name k`
AT 2. TO BE COMPLETED BY REPRESENTATIVE OF. WASTE -TIRE HAUL'' e
IiV1/MB 1Naste T reH:auler Uefiicle-�`R9e" istr�ation Numb'e`r �/ehicle License Number>>� incluiin "State Co"untr" �
� f I � / ,g,, _n�t'"' _ � F"3�"� ��� --��'� "/�.�-r'�IC-fie n..z�.S � �.:. i(� �� /� Y) :./•: -
!.
RT" 3
-.:TC
TO BE,COMPLETED BY REPRESEN'
_BE.GO.MPLETED.BY WASTE TIR&Hl
kt►inSite' (include CIWMB Site Numt
late Tires Received (Month Day%yearj
l
ire the num6er;of tires received he sarne as the number' & tires shipped in Part 17 Yes No* If NO 'please
omplete the boxes) *below. �
06- le ,Tires In this Shipment OR-> Vol"ume of tires in this:.Shi.pment 'We(g'ht of tires m this Shlp;ment
R>
(cubic; yds) O (Circle one) pounds tons t
certifythaYtheunf:rmation rovided,above istiue and correct, and that I have°been aithonzed b the State of California'or a. local. agency permifto
<� P Y
-cept waste tires f5 reuseor disposal. I am aware that falsification of this manifest may result in civilpenalties or administrative civil penalties'as
ascribed in,Public`Resources Code Section 42962 (a)and.(b). (See reverse side, of this form).;.
Waste TireL Destination Representative Signature
Date S -'3a d-� Printed Name Q E tsf x
f
C._T%!P. np..alP/lwa.Ctp TirP.rP/1P%A mr.: Yp"nW - PM/`P.CCII/�i�nllPPf/A/1-�:P.n1P./�nP.Cf%nAf%A/1 .0%fP.!. i/i%%1%f P.%n/III/nAl�-- il�/ARfP ;T%IP.HA//lP./: �Ri//P.--TWP.,nP.AIPr1Ti P
-
----------
DOLLARS
V QFOR T
0 CASH To
ACCTFROM
.HECK
AECK
.......................
PAID "
0 MONEY
ORDER
P.O. Box 297
90.333 Avenue 63
Mecca, California 92254
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