12-0528 (DSF)P.O. BOX 1504 �^� VOICE (760) 777-7012 t
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 5/16/12
Application Number: 12---00.00.0.52.8 Owner:
Property Address: 78405 COYOTE CANYON CT MICHAEL BALMUTH
APN: 770-240-005- - - 78405 COYOTE CANYON COURT
Application description: DEMO - COMML/OTHER LA QUINTA, CA 92253
Property Zoning: LOW DENSITY RESIDENTIAL
Application valuation: 35000
Contractor: D MAp
Applicant: Architect or Engineer: PREMIER BUILDERS
P.O. BOX 1329 A
INDIO, CA 92202 Y Lry o9l�
(760)296-1726
�' fr Lic. No.: 958992 CITY 6LA 0
FINANCE DEPT:
-------------------------------------------------------------------------------------------------
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am license oder provisi of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Profe �o als Code, d y License is in full force and effect.
License Class: B icens o 958992
ate:. tractor:
WNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I a exempt from the Contractor's State License Law for the
following reason (Sec. 7031 S, 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, 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 I 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
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 and policy number are:
Carrier EXEMPT Policy Number EXEMPT
AC I certify that, in the performance of the work for which this permit is issued, I shall not employ any
Y� person in any manner so as to become ubject to the wor ' compensation laws of California,
and agree that, if I should become s j t to t orke mpensation provisions of Section
,300 of the Labor Code, I shall fo th co wi t se provisions.
te: jl //IL plicant:
WARNING: FAILURE TO SECURE WORKERS' CO PENSATION 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, indemnity 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"ofwork rk for 180 da s will subject
permit to cancellation.
I certify that I have read this application and state that the above in. I agr to omply with all
city and county ordinances and state laws relating to building constaut rize presentatives
aft cou ty t enter upo the above-mentioned property for inspS I7 z
ate: I ignature (Applicant or Agent):
Application Number . . . . . 12-00000528
Structure Information
Construction Type . . . . . TYPE V, UNPROTECTED
Occupancy Type . . . . . . DWELLG/LODGING/CONG <=10
----------------------------------------------------------------------------
Permit . . . DEMO PERMIT
Additional desc . .
Permit Fee . . . . 45.00 Plan Check Fee
.00
Issue Date . . . . Valuation . . .
. 0
Expiration Date 11/12/12
Qty Unit Charge Per
Extension
BASE FEE
45.00
----------------------------------------------------------------------------
Special Notes and Comments
DEMO TO PREPARE FOR NEW GOLF CART GARAGE
& EXTENSION OF MASTER BATH. NO
STRUCTURAL DEMO PERMITTED FOR SFD, PER
APPROVED DEMO PLAN AND ADMIN SIGN -OFF.
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
RECORDING REQUESTED BY:
Lawyers Title - IE
WHEN RECORDED MAIL THIS DOCUMENT
%,� AND TAX STATEMENTS TO:
Michael Balmuth
C/O ROSS STORES
1372 Broadway,10th Floor
New York, NY 10018
Order No.: 69612446
Escrow No.: POL10175-CM
A.P.N.: 770-240-005.5
-pk: GRANT DEED
THE UNDERSIGNED GRANTORS) DECLARES)
DOCUMENTARY TRANSFER TAX IS $2,200.00
0 City of La Quinta
DOC # 2009-0303919
06/15/2009 06:00A Feo:9.00
Page 1 of 1 floc T Tax Paid
Recorded in Official Records
County of Riverside
Larry W. trard
assessor, County Clerk b Recorder
111111111111111111111111111111111111111111 IN 1
aoo�®��ammic�r
it�'7�1•:�
�� � L�L:IJE
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
Susan E. Schiffer, Trustee of the Susan E. Schiffer Trust UA dated April 26, 2002
hereby GRANT(S) to Michael Balmuth, a married man as his sole and separate property
the following described real property in the County of Riverside, State of California
THE LAND REFERRED TO HEREIN IS SITUATED IN THE COUNTY OF RIVERSIDE, STATE OF
CALIFORNIA, AND IS DESCRIBED AS FOLLOWS:
LOT 47 OF TRACT 28470-1, IN THE CM OF LA QUINTA, COUNTY OF RIVERSIDE AS SHOWN BY
MAP ON FILE IN BOOK 263, PAGE(S) 76 THROUGH 90, OF MAPS, RECORDS OF RIVERSIDE
COUNTY, CALIFORNIA.
ASSESSOR'S PARCEL NUMBER: 770-240-005-5
Dated: May 20, 2009
State of CafiforniE
County of ' ler sto(e } ss
O s �c o `? before me
n
a Notary Public, personally appeared
who proved ip me on the bas' of satisfactory evidence to be
the person whose name i re subscribed to the within
instrument and acknowled d to me that he/she/they
executed the a in hi a /their authorized ppaclty0
and that by f )!her their signature{ on the instrument(( e
persons), or hntity upon behal of which the person},
acted, executed the instrument
I certify under PENALTY OF PERJURY under the laws of
the to of a mia that the foregoing paragraph is true
and correct
WITNESS y hand offldial seal.
Signature
Signature of Notary
the Susan E. Schiffer Trust UA dated April 26, 2002
By: Susan E. Schiffer, TroWbe
elt" t. moon
emmiwton I 1 00165
fttary PuMW - comw o
NVOM146 Cotarlt►
1-10G1 01 t
• �00
��• N Oil �
(This area for official notary seal)
MAIL TAX STATEMENTS AS DIRECTED ABOVEi rS
C" -
Description: R.iverside,CA Document-Year.Doc= 2009.303919 Page: 1 of Z
Order: 8403274 Comment:
May 10, 2012
City of La Quinta
78-495. Calle Tampico
La. Quinta, CA 92253
Re: 78405 Coyote Canyon Ct, La Ouinta, CA 92253 (Permit),
To Whom. It May Concern,
In consideration for demolition permit, I hereby authorize.Premier.Builders to perform
the following construction on my residence as follows:
SCOPE OYWORK:
New Golf Cart Garage: I
-Demo concrete slab side/walkways
-Demo concrete block walls sand footings at. Trash & Air Conditioning enclosures.
Master Bath extension i
=Demo,water feature:at-garden
-Demo 4ft of concrete. slab sidewalks and tile
-Remove 'interior tile
Contractors information:
Premier Builders
PO Box 1329
Indio,_ CA 92202
760-775-5920
LIC# 958992
Should you have any questions please contact me at 212-819-3789.
V
k�, almu h
78405 Coyote Canyon
1La,Qui*a.,,CA:92253
212-819-3789
Email: Jacguelyn.Buonamassanros.com
tmail - FW: Copy of approval letter (Tradition Architectural) 5/10/12 1:47 PM
GONZALO GUZMAN III <
brC;c�lc"
Fw: Copy of approval letter (Tradition Architectural)
2 messages
r
Jacquelyn Buonamassa (NY-EAA) < Wed, May 9, 2012 at 7:19 PM
To:
This letter is all we need as far as HOA approval. I have a hard copy in office that I'll scan/email tomorrow along
with Grant Deed for you.
From: Brook Marshall [mailto:brook@dc.rr.com]
Sent: Monday, April 16, 2012 05:19 PM
To: Jacquelyn Buonamassa (NY-EAA)
Subject: RE: Copy of approval letter (Tradition Architectural)
Please see, copied and pasted, below.
March 8, 2012
Mr. Balmuth
78405 Coyote Canyon
La Quinta, CA 92211
Re: Lot 47, Tract 28470-1, 78405 Coyote Canyon
Remodel — Room Addition/Schematic Submittal
Dear Mr. Balmuth:
The Tradition Architectural Design Review Committee (ADRC) has reviewed and approved the
conceptual drawings with regard to your proposed room additions (golf cart garage/master bath
and closet). The following items will need to be addressed in your working drawing submittal for
final approval to start construction:
https://mail.google.com/mail/?ui=2&ik=38336b8445&view=pt&search=inbox&th=13733e6429da8c9c Page 1 of 3
Gmail - FW: Copy of approval letter (Tradition Architectural)
5/10/12 1:47 PM
1. Please clarify the enclosed yard space at the rear, right corner adjacent to the master
bathroom addition.
2. All property lines and setbacks should be indicated on the plans for review.
3. The committee assumes the new addition is at the same finished floor level and will be
built to match the existing colors and materials.
4. All existing and proposed plant material must be indicated on the final plan set. All plants
should be shown at full scale for proper approval.
5. All side yard gates are to be located so they are not visible. It appears a small wing wall
could be added to correct this condition.
Please contact Brook Marshall at (760) 219-8057 or by email at Brook@dc.rr.com with any
questions.
Sincerely,
Tradition Architectural Design Review Committee
cc: John Walling
ADRC File
From: Jacquelyn Buonamassa (NY-EAA) [maiIto:
Sent: Monday, April 16, 2012 2:06 PM
To: brook@dc.rr.com
Subject: Copy of approval letter (Tradition Architectural)
Importance: High
HI Brook,
My boss, Michael Balmuth, submitted architectural plans by his architect that were approved from the Tradition
Architectural Committee (I believe). He cannot locate the approval letter, can you scan & email me a copy for our
records?
Thank you in advance,
https://mail.google.com/mail/?ui=2&ik=38336b8445&view=pt&search=inbox&th=13733e6429da8c9c Page 2 of 3
Y
f
}
Gmail - Fw *Copy of approval letter (Tradition Architectural)
Jacque
Jacquelyn Buonamassa
}
t
Assistant to Michael Balmuth
Vice Chairman and CEO
Ross Stores, Inc.
,
1372 Broadway, 10th Floor I New York, NY 10018
}
5/10/12 1:47 PM
,I
f
< Wed, May 9, 2012 at 7:28 PM
Reply -To:
To: "Jacquelyn Buonamassa (NY-EAA)" <
Thanks
Sent from my Verizon Wireless BlackBerry
From: "Jacquelyn Buonamassa (NY-EAA)" <
Date: Wed, 9 May 2012 19:19:15 -0400
To: <
Subject: Fw: Copy of approval letter (Tradition Architectural)
[Quoted text hidden]
n
https://mail.google.com/mail/?ui=2&ik=38336b8445&view=pt&search=inbox&th=13733e6429da8c9c Page 3 of 3
�W) A 47oki
CITY OF LA QUINTA - PUBLIC WORKS DEPAR ENT GREEN SHEET�21
PUBLIC WORKS CLEARANCE FOR RELEASE OF BUILDING PERMIT
Form updated & effective 9/25/2009
Green Sheet approvals are forwarded to the Building & Safety Department directly by Public Works. Please DO NOT
submit the Green Sheet (Public Works Clearance) Packet to the Public Works Department until ALL requirements listed
below are complete. Incomplete applications or applications which cannot be processed will be returned to applicant.
Cohk�avlz�r
Date: S/ 10 / 112— Bevelopm: r e- V-
1 rS
Tract No.:Z-g 0 • I Tract Name:
Lot No. (s): U}
Address(s): —It LOS CvV o+c CAPiUah Phone Number: ( 40 ) Z-1 Z • 1 y i 5
The following are the requirements for Public Works Clearance to authorize issuance of a building permit from the
Building & Safety Department:
❖ CUSTOM HOMES: PROVIDE ITEMS #2, #3, #4, #5 & #7 BELOW
❖ TRACT HOMES: PROVIDE ITEMS #1, #2, #3 & #5 BELOW
#7
1. Attach Pad Elevation Certificates in compliance with the approved design elevation for building pad (maximum
allowable deviation of +/- 0.1 foot). Pad Elevation Certificates must be current (within 6 months of current date).
If a precise grading plan creates the pad for approval, please withhold green sheet submittal until a Pad Elevation
Certificate can be provided.
2. Attach geotechnical certification of grading plan compliance including compaction reports from a licensed Soils
Engineer. Recently rough graded residential developments which have a previously approved geotechnical
certification are exempt from this requirement.
3. Attach recorded final map or title information/grant deed showing proposed building locations are legal lots.
4. Complete the attached <1 acre per lot or infill project Fugitive Dust Control project information form, PM10 plan &
agreement or provide alternative & valid City approved PM10 plan set reference number or hard copy plan.
PM10 plans for commercial & residential developments (beyond 1 lot) are submitted separately with grading plans
& are subject to additional requirements. A current PM10 certification number is required.
5. Attach a copy of the rough or precise grading plan to the Public Works Department showing building location(s)
for pad elevation verification. AO flood zone developments will require an approved flood plain development plan.
6. Attach supporting documentation for wall plan, monument sign, grease trap or special facility installations.
7. Complete and sign the attached water quality management plan (WQMP) exemption form, if applicable. PW
approved building construction projects require either a WQMP or a completed WQMP exemption form.
Approved maps/plans may be viewed at the following link: httr)://www.la-quinta.org/PlanCheck/m search.aspx
I have reviewed and confirmed the requirements listed above as presented and find the improvements to be sufficiently
complete for construction of the proposed buildings/structures/walls/signs on the subject lot(s). Pursuant to my findings,
the above project may be released for building permit issuance.
This section completed by City aff.
Recommended by: Date: / (/ / 2
Public Works Distribution: ( ) Green Sheet to Building & Safety
( ) Green Sheet to Planning Department
Declined for approval for reason(s) as follow(s), please correct and resubmit:
TAChecklists - Forms & ApplicationMForms & Applications\GREEN SHEET cover & PM10 less than 1 Acre Revised 9-25-09.doc
City of La Quinta - PM10 Fugitive Dust Control Project Information
Construction Phase PM10 Agreement (<1 acre/lot or Infill Project)
Project Information
The
Project Contractor:
Project Phase
Project Name: ? ► C►v1 I e r v ,3
(check one)
Project Tract/Lot Numbers: Z 6 H -10 - I Ln{ `4 ^]
RConstruction
Demolition
Project Street Address: 1 y'0S e- CA y yoh Ct.
++$S_. 4-.
L-AQV V% �, ufi �I ZZS-3Total
I
Acres in Active
Construction (<1 acre per
Lot):
Anticipated Start Date: -5/1q / 2 Anticipated Completion Date: 110/ 30/ 12,
PM10 Contact
Please note: Dust control is required 24 hours a day, 7 days a week, regardless of
Information
construction status. Person listed below is responsible for dust control during business and
non -business hours.
Name:
lVo►-a z -*+Lo 4pVT_w►CAV1
Title:
0.)h
Company Name:
r v1 �C ✓�'
Mailing Address:
PO E�OX 1.3 y
City, State, ZIP Code:
VXd to Z2_0 Z_
PrimaryPhone #:
(so • 5 Si 20
Fax M
7 Z
24 Hour Emergency
Phone#:
YO • y7 Z • T7_5
Cell Phone #:
SCtVK.0
Email Address:
`Ke r C l r1�,0 d« mt, tj • Cot -i
PM10 Certificate M
Q Z
CV t O— 1� , "4032—
The above stated property owner (or authorized representative):
❖ Shall act as his/her acknowledgement of dust control requirements and their enforceability, pursuant to SCAQMD
Rules 403, 403.1, 401, 402, 201, 203 and PERP;
❖ Shall constitute an Agreement to comply with all project conditions as identified in the approved dust control plan.
❖ Acknowledges that dust control is required twenty-four (24) hours a day, seven (7) days a week, throughout the
period of project performance, regardless of project size or status;
❖ Shall ensure that each and every contractor, subcontractor and all other persons associated with the project shall
be in continuous compliance with all requirements of the approved dust control plan;
❖ Shall take all necessary precautions to minimize dust, even if additional measures beyond those listed in the dust
control plan are necessary;
❖ Shall authorize representatives of City/County to enter the property for inspection and/or abatement purposes;
❖ Shall hold harmless the i �/Crty aan5 representatives from liability for any actions related to this dust control
plan or any City/Coup inr ibat e t activities.
Signature of
or Authorized Representative
TAChecklists - Forms & ApplicationslForms & ApplicationslGREEN SHEET cover & PM10 less than 1 Acre Revised 9-25-09.doc
r
to
Date
iZ
Date
City of La Quinta - PM10 Fugitive Dust Control Plan (<1 acre per Lot or Infill Project)
This Fugitive Dust Control Plan shall take into account applicable SCAQMD Regulations Rule 403, 403.1, 401, 402, 201,
203 and Portable Equipment Registration Program (PERP).
❖ WATERING: Continuous watering is required to prevent dust and must occur a minimum of four (4) times daily.
Water shall be applied from an adequate sized metered water source to dry soils to prevent:
• Visible dust emissions >20% opacity
■ Visible dust emissions that travel >100 feet from the source (within site)
■ Visible dust emissions that cross any property line
❖ EDUCATION: The responsible dust control Individual and key personnel shall attend SCAQMD PM10 class and
obtain PM10 certificate number prior to construction activity (training information may be obtained by contacting
SCAQMD at (909) 396-2183).
❖ CONSTRUCTION & DEMOLITION ACTIVITIES: A copy of this approved Fugitive Dust Plan must be kept
on site. At least one short-term stabilization method must be used during off hours. At least one long-term
stabilization measure must be used within ten (10) days of ceasing activity.
❖ WEATHER MONITORING: Wind predictions shall be monitored.
❖ SIGNAGE: Approved signs shall be installed at a highly visible location. Please refer to the Coachella Valley
Fugitive Dust Control Plan Handbook for Construction Signage Guidelines.
❖ TRAFFIC: Construction traffic shall not be allowed on the pad, unless absolutely necessary. If vehicles operate
on pad, pad shall be kept firm and moist through hose watering and sprinklers; and a maximum traffic speed of
15mph will be enforced. Fugitive Dust shall be prevented by fencing off site to prevent unauthorized traffic on
pad.
❖ PARKING: Parking is not allowed on pad. All vehicles must park on street at designated areas only.
❖ TRACK OUT: Provide 24 hour street cleaning and track out system as approved by City Public Works
inspectors. No dirt on public or private roads. Track out shall be cleaned up within one (1) hour of incident and at
the conclusion of each workday.
❖ DIRT PILES: Dirt piles shall be limited to 50 cubic yards and built per California Building Code grading
requirements. Piles shall be kept moist or covered with tarp material. Larger dirt piles will require stockpile or
grading permit.
❖ FENCING: Provide PM10 fencing at perimeter of public roads and where applicable. Wood slat fencing can be
installed at rear of property and return 20 feet on either side if HOA restrictions apply. Block walls can replace
PM10 fencing during the construction phase.
❖ EQUIPMENT: Extra hoses and sprinklers shall be maintained on site.
❖ EXCAVATION MEASURES: All areas to be excavated or graded shall be pre -watered. Water shall also be
applied during excavation or grading operations.
❖ DUMP TRUCKS: Open top dump trucks shall be wet down, moist and covered with a tarp prior to leaving site.
❖ INACTIVE SITE: Within 10 days of ceasing of activities, re -vegetate or permanently stabilize as required.
❖ RECORD KEEPING: Fugitive Dust Control Plan records (i.e. self inspection records, records of use of chemical
suppressants, etc.) shall be maintained for 3 years by the Property Owner (or Authorized Representative).
Property Owner shall notify the City and SCAQMD within 10 days of completion of project.
TAChecklists - Forms & Applications\Fonns & Applications\GREEN SHEET cover & PM10 less than 1 Acre Revised 9-25-09.doc
Water Quality Management Plan (WQMP) Exemption Form - Whitewater River Region
Documentation of Project Not Requiring a WQMP but Requiring Site Design BMPs and Source Control BMPs
by Entitlement Conditions of Approval or Permit Conditions — WQMP Required for the Listed Change of Land
Uses or for Changes of Pollutant Stream (All Questions Below Must be Answered "No" To Exempt Project)
Yes
No
Entitlement or construction of new single-family hillside residence(s) that create 10,000 square feet, or
more, of impervious area where the pre -development natural slope is 25% or greater?
❑
Entitlement or construction of new single-family hillside residence(s) that create 10,000 square feet, or
more, of impervious area where the pre -development natural slope is 10% or greater where erosive
soil conditions are known?
❑
Entitlement or construction of new commercial and industrial development(s) of 100,000 square feet
more?
1:1or
Entitlement or construction of new automotive repair shop(s) including body, upholstery, paint,
exhaust, tire, transmission, engine or other automotive specialty repair. [Standard Industrial
Classification SIC codes 5013, 7532, 7533, 7534, 7537, 7538, and 75391?
❑
Entitlement or construction of new retail gasoline outlets disturbing greater than 5,000 square feet?
❑
Q
Entitlement or construction of new restaurant(s) (or potential restaurant shell space) disturbing greater
than 5,000 square feet?
❑
Entitlement or construction of new home subdivisions with 10 or more housing units?
❑
Entitlement or construction of new parking lot(s) of 5,000 square feet or more, or with 25 or more
parking spaces, and potentially exposed to Urban Runoff?
❑
Applicant
Information
Name and Title
(pd V1Za-LoVLKAtyn dwhC r
Company
✓ t t ALe Ns
Phone
-7(00 • .?,"?ejJ
Email
y e� l e r 6V1 � 0`4 r VV. Lk t
• (,Vr►-)
Project Information
Project Name
Type (SFH, Multi -Family, Commercial, Etc.)
�a-� Vel Vi L, PY10 GcrF SF 4
Location or Street Address
, Q)OS %O d fe_ (u h oo
Nearest Cross Streets
SZ wd
Municipality/County/Zip Code
La Quinta
Tract Number(s) and/or Assessor Parcel Number(s)
U y Jo • ( Y1 Zy 0 00T_ - S_
Other Location Information
Watershed
Whitewater River
Source Control BMP Information
Size of Project Area (nearest 0.1 acre)
< O • aG rC
Project Area managed with Site Design or Low
Impact Development (LID) BMPs (nearest 0.1 acre)
Is the project subject to onsite retention by City
ordinance or policy?
NO
Name of the Entity that will implement, operate, and
maintain the Source Control BMPs
K e -
Contact Name
Street or Mailing Address
City
Zip Code
Phone
TAChecklists - Forms & Applications\Forms & ApplicationslGREEN SHEET cover & PM10 less than 1 Acre Revised 9-25-09.doc
Check Item
To be
Performed
Source Control BMP Requirements - All Projects Require Non -Structural BMP Source Control
Non -Structural BMP (See Appendix H, Section 4.5.2.1)
The applicant shall comply with listed BMPs and applicable
Ongoing Irrigation System and Landscape Maintenance
provisions of the City's NPDES stormwater discharge permit,
If
Ongoing Litter Control
LQMC Sections 8.70.010 et seq. (Stormwater Management and
Discharge Controls), 13.24.170 Air/Clean Water);
�0NZ.4,.
Ongoing Drainage System Inspection & Maintenance
and (Clean
Print Name:
Education/Training for Property Owner, Operators, Occupants, or Employees
Riverside County Ordinance No. 457; the California Regional
Water Control Board Colorado River Basin Region
�1
Ot.�W
Activity Restrictions — Prohibition of Debris Blowing/Sweeping/Washing into Street/Storm Drain, Closed
Trash Lids, Restriction of Vehicle Washing
Title: t-"
Board Order No. R7-2008-0001 and the State Water Resources
Ongoing Street Sweeping at Private Streets and Private Parking Lots
Check Item
To be
Provided
Source Control BMP Requirements — Small Sloped Lots, Small Commercial, <10 Unit
Subdivisions, <5,000 Square Ft. Parking Lots, Etc.
Structural BMP (See Appendix H, Section 4.5.2.2)
Date: �l I
V1
I Storm Drain Inlet Stenciling and Signage
Phone: (JUD �'
—
J ► Z-0
Landscape and Irrigation System Design to Minimize Erosion & Nuisance Runoff
Protection of Slopes and Channels to Minimize Erosion
Multi -Family Project Use of Community Car Wash Racks
Wash Water Controls for Food Preparation Areas to Use Sanitary Sewer
Fueling Area (Design & Maintenance) Including PCC Surface, Canopy & Spill Prevention
Air/Water Supply Area Drainage (Design & Maintenance) Including Spill Area Containment
Trash Storage Areas (Design & Maintenance) Including Attached Lids, Storm Water Controls
Loading Docks (Design & Maintenance) Including Storm Water Controls, Dry & Frequent Cleaning
Procedures
Maintenance Bays (Design & Maintenance) Including Indoor Location & Storm Water Containment
Vehicle and Equipment Wash Areas (Design & Maintenance) Including Canopy & Containment
Outdoor Material Storage Areas (Design & Maintenance) Including Canopy & Containment
Outdoor Work Areas or Processing Areas (Design & Maintenance) Including Canopy & Containment
CC&R's, Maintenance Agreements or Other mechanisms will be used to ensure the ongoing operation,
maintenance, funding, transfer and implementation of the project -specific WQMP requirements. Legal
description and plat stamped by Registered Surveyor to be attached to the applicable CC&R or
Maintenance Agreement for recordation at Riverside County. (Optional Requirement to be reviewed on
a Project by Project basis)
n
BMP Acknowledgement
The applicant shall comply with listed BMPs and applicable
provisions of the City's NPDES stormwater discharge permit,
Signature:
LQMC Sections 8.70.010 et seq. (Stormwater Management and
Discharge Controls), 13.24.170 Air/Clean Water);
�0NZ.4,.
and (Clean
Print Name:
V-tw ►"J
Riverside County Ordinance No. 457; the California Regional
Water Control Board Colorado River Basin Region
�1
Ot.�W
Quality —
Title: t-"
Board Order No. R7-2008-0001 and the State Water Resources
Control Board's Order No. 99-08-DWQ.
Date: �l I
Phone: (JUD �'
—
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TAChecklists - Forms & Applications\Forms & Applications\GREEN SHEET cover & PM10 less than 1 Acre Revised 9-25-09.doc
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oty. Of 1A Quanta
Building a Safety Division
P.O. Box 1504,78-495 Calle Tampico
4 La.Quinta, CA 92253 - (760) 777-7012
Budding Permit Application and Tracking Sheet
Pemlit #
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Project Address: $ I.� 0,5' % iJ+G 1kA V1 0
wner's Name:. t L �' �� m
A. P. Number. (0 Z`1 O • O�
dress: $ (�s' to C K
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Legal Description: ..( -:i1f Lf I
ty, ST, Zip:
Contractor. 1K l t C r LtNz t� f '
Telephone: ]
Address: PO
Project Description:
City, ST, Zip: Cl ub Z
Telephone: '760 % 1 9-- SJ
De t n q fo Y
Stats Lic. # : 15_$ Z
City Lic. #:
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Arch., Engr., Designer: W41.1 t, ! (v Y+.'
Ltvaf t
Address: 4 s' O -drive.
City., ST, Zip: , h d t h h h� (i ' �' ZZ -10
t4o Y -mc ."D eKe AoL avusl'_".
Telephone: 140 St4O O
State Lic. #: w�h�rti r
-Construction Type:. k~ A& Occupancy: ASF
Project type (circle one): New,'n Alter Repair Demo
Name of Contact Person: ()yt7.g-6 4 rtt4u,n�
Sq. Ft.: y 8 r' # Stories: IN Unit;:
Telephone # of Contact Person:
Estimated Value of Project S, . Opo
APPLICANT: DO NOT WRITE BELOW THIS UNE
#
Submittal
Req'd
Recd
1- TRACMG PERMrY FEES
Plan sets
Pian Check submitted Item Amount
Structural Cities.
Reviewed, ready for correctlous Plan Check Deposit. .
Truss Cales.
"tied Contact Person Plan Check Balance_
Mile 24 Calks.
Plans picked up Construction
Flood plain plan
Plans resubmitted Mecharilcal
Giading plan
y , G •
2`' Review, ready for rnrrection ue / ectrical
SubeontactorList
Ca1ledContactPerson 000,
Plumbing
Grant Deed
Plans picked up SALL
H.O.A. Approval
Plans resubmitted Grading
IN HOUSE.,
''' Review; ready for correctionslissae Developer Impact Fee
Planning Approval
Called Contact Person A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Feu
Total Permit Fees