09-1013 (DEMO)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Appljcation_ Number:,
C
Property Address:
APN:
Application description:
Property Zoning:
Application valuation:
Applicant:
a
0p
09. 00001013
53710 AVENIDA CARRANZA
774-121-010-15 -000000-
DEMO - SINGLE FAMILY
COVE RESIDENTIAL
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Ti&t
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BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Architect or Engineer:
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 Prof e ionals Code, and my License is in full force and effect.
License Class: A -9B License No.: 650389
Date: / Contractor
_ 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).:
(_) 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 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 _) I, 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.).
1 _) 1 am exempt under Sec. , B.&P.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:
LQPERMIT
Owner:
LACROIX ROGER
53710 AVENIDA CARRANZA
LA QUINTA, CA 92253
Contractor:
JACOBSSON ENGINEERING CONSTR
P.O. BOX 14430
PALM DESERT, CA 92255 Fro-, (760)340-0194
Lic. No.: 650389
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 9/18/09
SEP 18 2009 191
WORKER'S COMPENSATI, CLARA!FA 'QUINVTi�
I hereby affirm under penalty of perjury one of the following declarations: ice [)E j,
I have and will maintain a certificate of consent to self -insure for workers' compensation, as "'L
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
issued.
I 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 765310106
I certify that, in the performance of the work for which this permit is issued, I shall not employ any
person in any manner soas to become bject to the workers' compensation laws of California,
and agree that, if I should become subje to the workers' compensation provisions of Section
37,OQ of the Labor Code, 1 shall forth ' omply with those provisions.
DateV Applicant:
WARNING: FAILURE TO SECU ORKERS' 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, its officers, 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 cess tion of work for 180 days will subject
permit to cancellation.
I certify that I have read this application and state that the above information i correct. I agree to comply with all
city and county ordinances and state laws relating to building construction, an hereby authorize representatives
oft)hisco my to nter upon the above-mentioned property for inspection pur S.
Date/ / 17-/-=Q-Signature-(Applicant-or Agent):
Application Number . . . . 09-00001013
Permit . . . DEMO PERMIT
Additional desc .
Permit Fee . . . . 45.00
Plan Check
Fee
.00
Issue Date . . . .
Valuation
. .
. 0
Expiration Date 3/17/10
Qty Unit Charge Per
Extension
BASE FEE
45.00
----------------------------------------------------------------------------
Special Notes and Comments
DEMOLISH FIRE DAMAGED HOUSE TO BARE
GROUND.
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
r
LQPERM[T
ENVIROcCHIECK, 1, NAM
Asbestos Testing ♦ Lead Testing # Microbial Testing ♦ Management ♦ Analysis # Environmental Assessment
ASBESTOS SURVEY
Garland Restoration, Inc.
Attn: Karin Evans
610 Richfield Road
Placentia, CA 92870
Report Date: September 14, 2009
Subject Property:
Roger Lacroix
53710 Avenida Carranza
La Quinta, CA 92253
Inspection Date: September 11, 2009
1.0 INTRODUCTION
This report presents the analytical results of the Limited Asbestos Survey performed on the subject
property listed above by Envirocheck, Inc.
2.0 LIIVIITATIONS
The findings set forth in this report are strictly limited to the time, date and scope of the investigation.
The results presented in this report are based on the analytical testing performed by the certified
laboratory. The results from the sampled locations are representative of the entire homogeneous
material/areas and not just the locations sampled. According to AHERA, 40 CFR, 763.87 (c)(1),(2) - A
homogeneous area is considered not to be Asbestos Containing Material (ACM) only when all required
samples collected from a homogeneous area indicate levels below regulated limits and a homogeneous
area is considered ACM when at least one of the required samples collected indicates levels above
regulated limits. This report does not guarantee that all inaccessible, hidden, or indistinguishable
materials will be identified or sampled. Samples were limited to the materials and locations listed on
the chain of custody. Materials/areas that were not sampled shall be presumed to be asbestos
containing until proven otherwise by appropriate sampling procedures. Square footages are estimates
only and should not be used for bidding purposes.
3.0 SAMPLING PROTOCOL AND TEST METHODS
The purpose of this Limited Asbestos Bulk Survey is as follows:
• The facility was inspected for the presence of suspect ACM and PACM where demolition or
renovation operations will occur.
• Envirocheck personnel identified all accessible and recognizable types of suspect ACM and
PACM.
• Asbestos survey and testing was performed by Mike Powers, CSST Number 07-4273 of
Envirocheck, on 09/11/09.
• The samples were submitted to Envirocheck's in-house laboratory, located at 2211 W.
Orangewood Avenue, Orange, CA 92868, (800) 665-7586.
• Envirocheck, Inc. NVLAP #200548-0
• The inspector performed an inspection for suspect asbestos containing materials listed above
following the provisions of 40 CFR Part 763.86.
2211 West Orangewood Ave # Orange, CA 92868 0 Telephone: (800)665-7586 # Fax: (714)891-3922
• The Inspector is Cal/OSHA certified and shall conform to procedures outlined in the EPA
Building Inspector Course.
• AHERA (Asbestos Hazard Emergency Response Act) sampling methods and protocols were
used.
• Each asbestos sample collected was analyzed utilizing the Method specified in Appendix A,
Subpart F, 40 CFR Part 763, Section 1, Polarized Light Microscopy (PLM) Method by a
NVLAP Certified Laboratory.
4.0 EXECUTIVE SUMMARY
4.1 Limited Asbestos Bulk Survey
The sampled materials that exceeded the EPA level of I% and the Cal -OSHA level 0.1% for
asbestos content were:
• None Detected
Table -4.2 Negative Results
Material:
Location:
Drywall Mud
Living Room
Drywall Mud
Master Bedroom
Drywall Mud
Southwest Bedroom
Drywall Mud
Garage
Drywall & Mud Composition
Kitchen/Nook
Blown In Insulation
Attic
Roof Shingle
Roof
Roofing Felt
Roof
800)665-7586 ♦ Fax:(714)891-3922
5.0 STATEMENT OF QUALIFICATIONS
LABORATORY ACCREDITATION
Envirocheck, Inc. is a fully accredited and certified laboratory, maintaining proper State and Federal licenses,
permits and certifications. Our employees receive through training in project management, supervision, inspection
and asbestos abatement training. Continuing education is maintained through programs designated to renew
certification and to work with special supervisory and management needs.
Corporate accreditation and credentials are earned by proven proficiency through a number of independent audits
and investigation. Since their inception, Envirocheck, Inc. has consistently been awarded all credentials and
accreditations sought.
NIST/NVLAP
Nation Institute of Standards and Technology
National Voluntary Laboratory Accreditation Program
Lab # 200548-0
Accuracy of Polarized Light Microscopy (bulk) analysis is evaluated by participation in NIST's National
Voluntary Laboratory Accreditation Program (NVLAP). AHERA requires NVLAP accreditation for bulk asbestos
analysis (by PLM) performed during school building surveys.
NIST, formerly NBS-National Bureau of Standards, primarily focuses on development and establishment of
quality control standards for laboratories. NIST ensures that standards are met through a thorough accreditation
process. Accreditation for laboratories performing analysis of bulk materials for the presence of asbestos is
awarded after the laboratory successfully passes an on-site inspection, during which the facility, technicians,
processes and record-keeping are carefully evaluated. Additionally, each quarter, the laboratory must successfully
analyze audit bulk material samples for the presence, type and percentage of asbestos.
UALITY ASSURANCE
Envirocheck, Inc. thoroughly monitors quality control through a detailed program evaluating and documenting the
ability to consistently reproduce analytical results. To accomplish this, we have developed a standard set of
protocols that encompass sample collection, handling, analysis, and reporting. Data quality is evaluated based on
both inter -laboratory control and duplicate analysis.
All PLM (Polarized Light Microscopy) and PCM (Phase Contrast Microscopy) samples taken or received by
Envirocheck, Inc. undergo proper chain -of -custody and log -in documentation. Contamination of bulk samples is
controlled by ensuring that only qualified personnel collect the samples in an approved container and that PCM is
determined by blind replicate analysis on 10% of all randomly selected samples by an Envirocheck, Inc. Quality
Control Manager and each microscopist. Each microscopist is issued one reference slide per day for analysis.
Additionally, quality control is maintained by:
Polarized Light Microscopy (PLM): On a quarterly basis, we exchange round robin samples with two other
laboratories in our area. Our sample results are compared with the results of the other laboratories for asbestos
presence, type and percentage composition. Duplicate and referenced samples are issued on a daily basis by the
Quality Control Manager and also are analyzed for asbestos presence, type and percentage. The data for these
quality control activities is then compiled and control charts are produced to help interpret the sample results with
regard to inter/intra analyst precision and accuracy, as well as inter/intra laboratory precision and accuracy.
Phase Contrast Microscopy (PCM): Each analyst's Coefficient of Variation (CV) is determined by daily analysis
of reference slides. The established CV for the analyst is then used to verify that 10% blind recount of all samples
is within acceptable limits. Regular updates if intra/inter analysis and intra/inter laboratory control charts are
produced form the data collected. Round robin sample exchange is performed from PCM samples, as was
described for PLM.
2211 West Orangewood Ave #Orange, CA 92868 ♦ Telephone: (800)665-7586 # Fax: (714)891-3922
6.0 ASBESTOS RELATED TERMS
AHERA — Asbestos Hazard Emergency Response Act (Regulates School Facilities)
ASHARA — Asbestos School Hazard Reauthorization Act. (includes public and commercial buildings under
AHERA regulation)
ACM — Asbestos Containing Materials (materials containing greater than one (1) percent by weight)
ACCM — Asbestos Containing Construction Materials (CAL-OSHA's term for materials containing greater than
one tenth of one (0.1) percent by weight)
PACM — Presumed Asbestos Containing Materials (materials considered asbestos containing without laboratory
analysis)
CAC — Certified Asbestos Consultant (State of California certified individual allowed to perform all aspects of
asbestos related inspection, management, planning, and design work and to direct CSST(s) and review and execute
asbestos reports under state law.)
CSST — Certified Site Surveillance Technician (Allowed to perform all aspects of asbestos related inspection,
management, work under the direction of a CAC.)
CAL- OSHA a.k.a. (ROSH) Division of Occupational Safety and Health (California Governing body regulating
worker protection)
OSHA — Occupational Health and Safety Administration
NIOSH — National Institute of Occupational Safety and Health
EPA — Environmental Protection Agency (Regulates Environment and Waste Stream)
DOT — Department of Transportation
NESHAPS — National Emissions Standard for Hazardous Air Pollutants
SCAQMD — South Coast Air Quality Management District (local division of NESHAPS)
NVLAP — National Voluntary Laboratory Accreditation Program
AIHA — American Industrial Hygiene Association
CFR — Code of Federal Regulations
CCR —California Code of Regulations
PLM — Polarized Light Microscopy (also known as "Bulk" sample)
PCM — Phase Contrast Microscopy
TEM — Transmission Electron Microscopy
Laboratory Report Terms:
ND- None Detected
A — Area Sample (air monitoring)
AA - Area After (Clearance Type Sample)
P — Personal Sample (Employee monitoring type sample)
EX — Excursion (Employee monitoring type of sample during peek activities)
BK- Blank (used for quality assurance)
2211 West Orangewood Ave ♦Orange, CA 92868 ♦ Telephone: (800)665-7586 ♦ Fax: (714)891-3922
7.0 CERTIFIED ASBESTOS CONSULTANT SIGNATURE P
Any individual performing services as an asbestos consultant or site surveillance technician as
referenced and defined in section 1529(b) of Title 8 of the California Code of Regulations must
be certified by the State of California, Division of Occupational Safety and Health (DOSH).
Asbestos consultant shall maintain copies of AHERA training certificates for management
planner, abatement project designer, abatement contractor and supervisor, and all subsequent
annual refresher courses. The complete abatement project designer course certificate is only
required for certifications provided after July 1, 1994. Site surveillance technician applicants
shall maintain copies of AHERA training completion certificates for inspector, and abatement
contractor and supervisor, and all subsequent annual refresher courses. Certificates for
abatement worker and abatement project designer may be utilized in lieu of the abatement
contractor and supervisor certificate. Specific qualifications are required pursuant to section
1529(0) of Title 8 of the California Code of Regulations for certification. The educational
qualifications, (diploma, official transcript, or other proof), and qualifying work experience as
specified in Business and Professions Code sections 7184 and 7185 have been met by the
individual(s) performing asbestos related consulting activities or site surveillance technician
activities. Qualifying work experience includes technical work associated with asbestos
consulting activities. Written references attesting to the applicant's qualifying work experience
which are certified under the penalty of perjury as required.
Vinh Q. Pham, CAC# 03-3356
2211 West Orangewood Ave ♦Orange, CA 92868 ♦ Telephone: (800)665-7586 # Fax: (714)891-3922
Bin #
Qty of La Quinta
Building &r Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
Project Address:5 3 1/6 C Jq f'r0l"IOwner's
Name: C.,— LC c -A
A. P. Number:
Address: 53 <'Z> ::Lt-7r-Y-C"V-t z -11q
Legal Description:
C
City, ST, Zip: 4,9 C,, C t
Co
T
Tele hone.
Address:
Project Description:
City, ST, Zip:
Telephone:
. ..... .....
. .. .. . .. .....
X ..... ........
State Lic. #
City Lic. #.-.
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone:
............
........
Construction Type: Occupancy:
State Lic. #:
Project type (circle one). New Add'n Alter Repair Demo
Name of Contact Person: D G /—A c,,C -,rz
Sq. Ft.:i
es: # Stofi
# Units:
Telephone # of Contact Person. 76/L z75- Q/47
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
'Submittal
Reqld
Rec'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount'
Structural Cales,
Reviewed, ready for corrections
Plan Check Deposit
Truss CaIcs.
Called Contact Person
Plan Check Balance.
Title 24 Cales.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2"' Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees