9905-087 (DEMO).. r n • F.ir�' a H •.
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Phi ter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date �!
272(i'19 A J1 C21,HAZ Q�pl,a2i)t
ate~ Signature of Contractor
Ili1 j r
OWNER -BUILDER DECLARATION
I hereby affirm under penalty.of perjury that I 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).
( ), I, as owner of the property, am exclusively contracting With licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ), I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
i 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.
• (X) 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 & policy no. are:
Carrier Policy No.
S'I'A.7i; %<`fitt�r'� �9ti:S 3a•-11099:
(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 subjectto the
workers' compensation laws of California, and agree that if I shoyld become
subject to the workers' compensation provis ons; of Section 3700%f the,Labor
C9cle, I shall forthwith comply with those provisions.
Date:' �� Applicant f f
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. - p
1. Each person upon whose behalf this application is made & each person�at
e whose request and for whose benefit work is performed under or pursuant jo
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless .the City of La Quinta, its officers, agents and employees.
2.:Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work_for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
L�orrect. I agree to comply with all City, and State laws relating to the building
C onstruction, and hereby authorize representatives of this, City to enter upon,
/Si
above-mentioned property for,inspec lion purposes
Date "
r
iature (Owner/Agent) t, / % +• k
Q
BUILDINlG PERMIT' PERMIT"
DATE VALUATION / LOTTRACT
y
JOB SITE `]:y,.''�'�.� ���.iaYVY� ti � t�
ADDRESS Y�y���r� �l7
APN ,1'�i�-f�L�����
OWNER
CONTRACTOR/DESIGNER/ENGINEER
Y4O�ND."TROLL
i&M CON:TRUCON
10ALM SPRINGS CA 92204
(7-60•)322-6918 C13L O, 4906
USE OF PERMIT
C'OJML�"sTIXY DrE.1vtUI TS1 )O S .18VILlDtAi,Li, &LAD FOOTINGS AM
CKA1N I,fNK MNC.S..
PE,RMITFE'R, SUMMARY
DEWOLiTIONI xE 9.01,000-423-(21IO 3.Eft1
r
,
;�i 'MAL (�NS"1•,R EC; Q_ N.Al�i;D PLAN CHECK
$4.5,00
MAY 0 5 1999 :1°�_I, t ,,1%111 �'�+;CS, DUE ����
$45.0
J.I TY0 F LA 0 6 i N Ti., �
RECEIPT
DATE
BY�r
DATE FINALED
INSPECTOR
a
INSPECTION RECORD
10
OPERATION
DATE
INSPECTOR
OPERATION
DATE
r
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
FireDiace 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 Pibg. 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:
`/LG
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)
w
SCAQMD NOTIFICATION OF DEMOUTION OR ASBESTOS REMOVAL
�► MAIL ORIGINAL 70 SCACIMD, ASBESTOS NOTIFICATIONS, FILE # 55641, LOS ANGELES CA 90074.5641
WASTE TRANSPORTER 92
WASTE STORAGE SITE BRICI= ENyIRONHOTAL
ADDRESS
. _ ADDRESS 957 W. BEECE STREET
C•TY 4 STATE
ZIP CITY SAN BERNARDINO STATE CA
CONTROLt: OESCRISE'NCRK FRAC'ICES AND CONTROLS TO BE USED AT THE RENOVATION AND DEMOLITION SITE Pnxedur y DP 9241;
For asbestos removals circle the ccmbination of Rule 1403 procedures used. Procedure.4 and 5 submft plans forA0M0 prior approval.
ASBESTOS DETECTION PROCEDURE: CIRCLE THE PROCEDURES AND ANALYTICAL METHODS USED TO OET ERMINE ASBESTOS iN THE
Bulk Sampling, Inspection. Survey, PU.1. ?CIA, T eA. Assumed as Asbestos, Describe Other.
DISPERSION STAINING USING NIOSH APPROVED I�TIIOD #740POLARIZED LIGHT
PSICROSCOPY AND
FJ' R DEMOLITIONS GIVE THE CCMIDA.NY NAME AND DATES OF ; HE ASBESTOS REMOVAL
rUZ'J"utKED DEMOLITION SEND A CCPY OF THE ORDER AND GIVE THE AGENCY NAME
-
-;UT PERSON:
DATE OF ORDER: - TITLE
DATE ORDERED TO BEGIN:
�.� QUICKutNCY ASBESTOS REMOVAL GIVE THE NAME AND PHONE NUMBER OF THE PERSON DECLARINGIAUTHORIZING 7HE EMERGENCY. DATE AND HC';:R
CF EMERGENCY AND OESCRIEE THE SUDDEN. UNEXPECTED EVENT:
EXrt,UN HO'N THE EYENT'NCt,'LO cAUSE'.:NSAFE CONDITIONS. EQUIPMENT DAMAGE OR UNREASONABLE FINANCIAL BURDEN:
wro t tNGENCY PLAN: DESCRIBE AC—,ONS AND PROCEDURES TO BE FOLLOWED IF UNEXPECTED ASBESTOS IS FOUND DURING OEMOUTICN OR NONFRIA8LE
AS'oESTC$ MATERIAL BECOME CRUMBLED. PULVERIZED. OR REDUCED TO POWDER. REVISED NOTIFICATION LETTERS WILL BE SL"NT
IFIWIIEN APPROPRIATE. - REMOVAL WILL BEYOONE WITHIN STATE, FEDERAL, CAL/OPIZ.SIIA, EPA RULES �
TRAINING CERTIFICATION:: Cendy chat an individual trained in the provisions of regulation AO1A0 Rule 1403 and NESHAP writ be on site duringthe removal
evldcnce that the required training nas teen accomplished by this pers will dable ( to on during normal busines s'n'ours. o a d
CRI,EY ENVIRONMENTAL % ��� 9
CCIM—any'NName MY tNA ZEITS
Print name eww/opermor
INFORIAATION CERTIFICATION: ! cetvfy that the above information is correct n I have
BRI -Name Q1p�0
�omoanyName 'ML -L MajtNA ZEITS
Print name
•mower/operator
SECRETARY 3 —2,q—C?6)
Tittle of'Uwioperator Date
required attachments.
SECRETARY
Tittle of •ewer1operaicr Date
ot,ficauens are not aoceolea without the required asbestos fee (AOMO Rule lerill: vals o s than 100 square feet are exempt from notifies—aon and fees.
=!ease make checks Payaofe to 'SCACMD'. Fees are per notification, not refundable, and vary according to the asbestos amount to be removed. Fees are as ,C,;Icws:
'��'•� 100 TO 1.000 SQUARE
``C'•t 1.001 TO 5,000 SQUARE S 10'40 DEMOLITIONS
5 78.60 $ 26.20
•�'•1
5.001 T010.000 SQUAR= ===7REVISIONS_$183.50 S 10.40
',LORE THAN 10,000 SQUARE: CANCELLATIONS S 00.05288.30 PROCEDURE 4 OR 5 PLANS
S2AB.27
ATTENTION: RETURNED CHECK CHARGE 525.00
Keep a copy of your notafiption. State law requires that you provide a copy of tha demolition notification to Building and Safe
ty oeiore issuance cf a
cem-nton cemitt. For cuestions t rl 909.396-2336. For your convenience please mail and do not hand cant'
MAIL ORIGINAL TO: SCAOIAO. ASBESTOS NOTIFICATIONS. FILE x 55641, LOS ANGELES CA 90074.5641
TELEPHONE: (909) 396.2335 FAX: (909) 396.3342 FAX BACK FORMS: (909) 396.2550 WEB SrrE: HTTPJNVWW.AC5IO.GOV
v c :. _... 3 faronone •-"91
SOUTH COAST
AIR QUALITY MANAGEMENT DISTRICT
NOTIFICATION OF DEMOLITION OR ASBESTOS REMOVAL
21865 E. Copley Drive, Diamond BarNS, FILE
91765-4182 (909) 396-2000
. MAIL ORIGINAL TO SCAPHO
OMD USE NLY SCREEN BY RECEIVED , ASBESTOS NOT1FiCAT10LE # 55641, LOS ANGELES CA 90074-5641 �
AOI POSTMARK
COMPLETED BY MYRNA ENTERED BY NOTIFiCATICN
COMPANY g$ICKLEY i ��r�I
II'TAL PHONE 909-888-2010
DATE 3_29_99 CHECK
' 11 n" /2ql FEES 10.40
NOTIFI(;klONTYPE PROJECT?2382_99
0"IG u� REVISION DATES
PROJECT TYPE OE
REVISION OTHER (highlight)
CANCELLATION
S!OLI'iCil ORDEREI] DEMOLITION
RENovAnoN (removal) E.IERG:NCY REMOVAL PLANNEo RENO (;rrUa:l
'
SITE INFORMATION c
I „ITE NAME
VACANT HOUSE
SITE ADDRESS
79-410 HWY 111
CITY CROSS STREET DUNE PALMS ROAD
.. LA QUINTA STATE CA
OESCRIEE'NORK LCCATIO.I ZIP COUNTY RIVERSIDE
BUILDING 31ZF;SO,: � I N.E. OFFICE AND EXTERIOR OF BUILDING
.
1,000 NUMBER OF FLOORS
BLDG PRIOR t PRESENT USE I,,�,E�C 1 BUILDING AGE (YEARS) 40 NUMBER OF OWE(! ING LIMITS 1
' HOSPITAL INDUSTRIAL Other
OFFICE PUBLIC BLDG. RESIDENCE SCNDDL $NIP
SITE •JWNErc� RAY TROLL
ADDRESS 2323 N. TUSTIN AVE
Clrr SANTA ANA STATE
CA ZIP 92705 CONTACT GEORGE MARANTZ
RPHONE 760_322_6918
EQUIRED BUILDING
INFORMATION CA
YEc NO ASBESTOS �,'
PRESENT? SURVEY? YES ASEESTOS YES NO 8UIL)ING TO Bc" YES h'C
PROJECT DATES REMOVED?OEMOUSHED?
I START 4_15-99 ENp '
ASBESTOS AMOUNT TO BE 4-16-99 WORK SHI am•p
REMOVED (Ins FRIABLE
quare fee!) CLASS I CUSS it
400 15 TOTAL REMOVED;aad row;
• ASBESTOS REMOVED FROM I 415 '
SURFACES I
DESCRIBE PIPES COMPONENTS '
ttTYPE 8 AMOUNT OF I .ACOUSTIC CEILING
ASBEST03 (in square feet! I LINOLEUM INSULATION
FIRE ?ROOF NG
400 DUC'ING STUCCO
FLCOR TILES (VAT) MAS
11 ORY WALL PLASTER TRANSITE i
t ROOFING OTHER
• 15 (desrnbe)
CONTRACTOR INFORMATION I
I CSL9 UCENSE 9 610414
' OSHA REG 49
NAME BRICKLEY ENV '�°MDIp 76397
���`�' ADDRESS
C,rr S 957 W. REECE STREET
AN B
ERNARDINO S7ATc_
CA ZJF 92411 SITE SUPVR LARA/BRICKLEY i
WASTE TRANSPORTER PHONE ('.OMEZ LARGENT PHONE 909-888-2010
ADDRESS EN
BRICKLEY ENVIRONMTAL ( LANDFILL =SA LAND BE
( 957 W, REECE STREET
RECLAMATION CO.
ADDRESS
1201 GLADSTONE AVE
_ SAN BETZ2`IARDL'd0 STATECAZP .
92411 CIN AZUSA STATE CA yip
91102