0210-028 (DEMO)M
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that 1 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 # Lic. Class Exp. Date
692.2; 4 B HIC % t 1%3 I AE It
Date %! 7 Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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).
( ) I am exempt under Section , B&P.C. for this reason
Date r' /' 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.
(�) 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 STATEFUND ND Policy No. 044-01"0014315#
(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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions]
_Applicant e A `
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 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 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
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. =
Signature (Owner/Agent) * ""••. Date 1_21_
BUILDING PERMIT PERMIT#
,
�.�. ~
LY+�Vo Ci
DATE VALUATION LOT TRACT
10/01)2(X 9.00 . YJ#
JOB SITE VAPN
ADDRESS W"45 (+&y eZ CADS
OWNER CONTRACTOR / DESIGNER / EN (NEER
LA Q11'�hT'A:A GRILL, LLC C L C3• CON STRUC 1011
7 8.043 CAUX CA= 965NOR1i.m;'COND AVERMY
LAQtT71TCA CA 9223:3"` UPIA D -CA 91786
9ay)95�2�9� i5 (n, .LO ?4539
USE OF PERMIT
):)FMO OF C)t,• IR-A.i3lr.AT NO%TH £;,fit..' T C;t7lZNEP. OF P110 r'I+'.,R's Y
DEMOLITION RX' 101-000-423-000
SPU TOTAL WWOTRUM101.T AND P hN• CAFF- ,
$45.00
$0.00
D A
OCT 0 11002
RECEIP /� ;
BY
DTE INALED
INSPECT jP
FINANCE ERT - 1 - '`
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
I DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
_
Underground Electric
Underground Plbg. Test
;Final
Gas Piping
r PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utiliy Notice (Perm)
COMMENTS:
10/01/2002 14:04
P.O. Hox 55329
Riverside, CA 92517
(909)624.1665
7603237743
SCOTT MORRISON & ASS
SCOTT MORRISON & ASSOCIATES
ASBESTOS SURVEY REPORT
Completed On
October 1, 2002
PLM093000202
Client La Quinta Grill
clo Ken West
Project: 7$-045 Calle Cadiz
La Quinta, CA
(go" demolition site)
PAGE 03
31855 Date Palm Drive, Ste. 03-507
Cathedral City, CA 92234
(840) 824-3353
On September 30, 2002 an asbestos inspection and bulk sampling was conducted at the above project
address. Bulk samples were taken of all suspect asbestos containing building materials (ACBM) at the
request of the client named above. A total of (2) bulk samples were submitted to Carolina
Environmental, Inc. in Cary, NC (NVLAP Code 101768-0 and Cal. Environ. Lab. Cert. #2483) to estimate
the percentage of asbestos by volume and determine the types) present _
Carolina Environmental, Inc. determines percentages and type .of asbestos by using EPA approved
method 6004v4-82-020: Interim Method for On Determination of Asbestos in Bulk Samples. Asbestos is
quantified by using the visual arena estimation technique and can only determine the approximate
pvroentage 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 1528) requires bulk sampling be c andioad according to the A.H.E.R_A. protocol
provisions of 40 CPR Part 763.86. The A_H_E.R.A. protocol recommends three (3) or more friable
surfacing samples from a homogeneous area be collected and analyzed before any building materiel is
determined to be non -asbestos. containing.
ASBESTOS INSPECTION BY: Scott Morrison, DOSH 092-M48
BULK SAMPLES ANALYZED BY: Carolina Environmental, Inc., NVLAP #101768-0
The results on the following page(s) indicate that asbestos was detected in 00 of the 02 samples
analyzed.
(1)
OCT -1-2002 TUE 02:26PM ID:C & G Construction ' La,Quinta PAGE:3
10/01/2002 14:04 7603237743 SCOTT MORRISON & ASS PAGE 04
SCOTT MORRISON & ASSOCIATES
P.O. Sox 55329 31855 Date Palm Drive, Ste_ #3-507
Riverside, CA 92517 Cathedral City, CA 92234
(909) 624.1665 (800) 87A-3353
PL.M093000202
Sample #KW --1 Type of material: wail panel
Location: ground debris throughout garage site
Area: 30' x 60'
Friable:yes Results: none detected
Sample #KW -2 Type of material: felt paper- black
Location: dumpMer on garage site
Area: southwest comer of garage site
l=riable:yes Results: none detected
Note: Samples were taken from a 30' x W demolition area.
Note: All asbestos containing building materials) containing greater than 1.0% asbestos by volume or
weight, must be removed by a state certified asbestos abatement contractor prior to any demolition or
conovation of the property.
lnspWor.
Scort G. lllbrrison
Certified Asbestos Consultant
DOSE 2-0248
(2)
OCT -1-2002 TUE 02:27PM ID:C & G Construction / La Quinta PAGE:4
10/01/2002 14:04 7603237743 SCOTT MORRISON & ASS PAGE 02
SCOTT MORRISON & ASSOCIATES
P.O. Box 55329 31855 Date Palm Drive, Ste. 0-507
Riverside, CA 92517 Cathedral City, CA 92234
(949) 624-1$65 (800) 824-3353
INVOICE
Client: La Quints Grill
cio Ken west
Project: 78045 Calle Cadiz
La Quinta, CAS
Date: October 1, 2002
File nome:PLM0930#0202
Inspection date: September 30, 2002
asbestos inspection/ bulk sampling (residential)_ $180.00
02 total bulk samples for analysis (PLM) 9 $20.00 each m $40.00
# hours of travel time @ $ each = included
Total amount due $220.00
Please send payment to: 31855 Date Palm Drive, Ste. #3-50T
Cathedra! City, CA 92234
4
Terms- due upon receipt.
Thank you.
OCT -1-2002 TUE 02:26PM ID:C & G Construction / La Quinta PAGE:2
La Quinta Grill
Fine Foods & Celebration
78-045 Calle Cadiz
La Quinta, Ca. 92253
September 27, 2002
To Whom it may concern,
As a managing member of La Quinta Grill, L.L. C., I do hereby give
authorization to C&G Construction Company for the demolition and
removal of a garage on the property of La Quinta Grill restaurant at 78-045
Calle Cadiz, La Quinta, California.
Patricia Eisele ok
PH. mg