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04-4533 (DSF)TA -4f 4 4 agwo BUILDING & SAFETY DEPARTMENT P.O. Box 1504 (760).777-7012 78-495 CALLE TAMPICO FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-7153 r a r _ !) Mi Y 2 2004 -A QUINTA BUILDING PERMIT Application Number . . . . . 04-00004533 Date 5/24/04 Property Address . . . . 46235 JEFFERSON ST APN: 649-071-015-24 -2190 - Application description . . . DEMO - COMML/OTHER Property Zoning . . . . . . LOW DENSITY RESIDENTIAL Application valuation . . 0 Owner Contractor ------------------------- CITY OF LA QUINTA ------------------------ EMERY LAND CLEARING & GRAD INC 78495 CALLE TAMPICO. P.O. BOX 1009 LA QUINTA CA 92253 THERMAL CA 92274 (760) 391-5840 WCC: STATE FUND WC: 116532004 04/12/05 CSLB: 600283 11/30/05 CCC: C21 -------=------------------ Structure Information ------------------------- Occupancy Type DWELLG/LODGING/GONG <=10 Flood Zone . . . . . . .. NON -AO FLOOD ZONE --------------------------------------------------------=------------------- Permit . . . . DEMO PERMIT Additional desc Permit Fee . . . . 45.00 Plan Check Fee .00 Issue Date . . . . Valuation . . . . 0 Qty Unit Charge Per Extension -.--------------------------------------------------------------------------- BASE FEE 45.00 Special Notes and Comments COMPLETE DEMOLITION OF EXISTING HOME AND IMPROVEMENTS 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 a r _ !) Mi Y 2 2004 -A QUINTA P.O. BOX 1504 a 'G`�� 78-495 CALL$ TAMPICO VOICE (760) 777-7012 LA QUINTA, CALIFORNIA 92253 4 4 FAX (760) 777-701 1 BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153 Application Number: 5 3 Date: Applicant: Architect or Engineer: Applicant's Mailing Address: Architect or Engineer's Address: Lic. No., BUILDING PERMIT DECLARATIONS I hereby affirm under penaltyof LICENSED CONTRACTOR'S DECLARATION perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professmonals Code, and my License is, full force and effect. // License Class cense No. (0 0 DL8,3 Date 2�� V� c r I hereby affirm under penaltyof p OWNER$UI ER DECLARATION perjury that I amexem 1 from the Contractors' 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 Contractors' 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).): U 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 or 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.). U 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 oontractor(s) licensed pursuant to the Contractors' State License Law.). U I am exempt under Sec. , B.8 P.C. for this reason Date. Owner 'I herebyaffirm under WORKERS' COMPENSATION DECLARATION 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 issu My grke compensatio ' mance carrier and policy number are: /C3rtier_ r�� Policy Number _ I certify that, in the performance of the work for which this permit is issued, I shall not employ an y person in any manner so compensation laws of California, and agr a that, if I should become subject to the workers' compensation provisions of Saectios to become700 of the Code shall r� forthwithcomply with those provisions. /Date !i v ( /Applicant WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGEYINLAWFUL. 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. I hereby affirm under penalty of perjury that there is a construction lending CONSTRUCTION agency for the Performance of C he work for which this � permit is issued (Sec, 3097, Civ. C.). Lender's Name Lender's Address IMPORTANT APPLICANT ACKNOWLEDGEMENT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on this a 1. Each person upon whose behalf this application is made, each person at whosework pWmcabon• issued as a result of this application. the owner. and the applicant, each agrees to, and shall, defend, indemnity and hold haris mless under City of La nOuinta any permit 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 100 day; from date of issuance of such pertniL or cessation of work for 160 days will subject permit to cancellation. I certify that I have read this application and state that the above information is Matt I agree to comply with all city and county ordinances and state laws relating to building construction and hereby authorize representatives of this county to enter upo the a tinned property for inspection purposes. /Date �'�1 �� nature (Applicant or Agent): SCOTT MORRISON & ASSOCIATES P.O. Box 55329 Riverside, California 92517 DOSH 92-0248 ASBESTOS SURVEY REPORT Completed On May 08th, 2004 PLM0427#0927 Client: Tom Hartung's Office City of La Quinta Redevelopment P.O. Box 1504 La Quinta, CA 92253 Project: 46235 Jefferson Avenue La Quinta, CA (single family home with attached garage) (909)624-1665 (800) 824-3353 On April 27th, 2004 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 (9) bulk samples were submitted to Carolina Environmental, Inc. located at: 107 New Edition Court in Cary, NC (NVLAP Code 101768-0 and Cal. Environ. Lab. Cert. #2483) to estimate the percentage of asbestos by volume and determine the type(s) present. Carolina Environmental, Inc. determines percentages and type of asbestos by using EPA approved method 600/M4-82-020: Interim Method for the Determination of Asbestos in Bulk Samples. Bulk samples are analyzed by PLM (Polarized Light Microscopy). Asbestos is quantified by using the visual arena estimation technique and can only determine the approximate percentage 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 1529) requires bulk sampling be conducted according to the A.H.E.R.A. protocol provisions of 40 CFR 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 material is determined to be non -asbestos containing. Scott Morrison & Associates conducts asbestos inspection surveys following the A.H.E.R.A. inspection protocol. ASBESTOS INSPECTION BY: Timothy Morrison, DOSH #02-3142 BULK SAMPLES ANALYZED BY: Carolina Environmental, Inc., NVLAP #101768-0 (1) P.O. Box 55329 Riverside, California 92517 SCOTT MORRISON & ASSOCIATES DOSH 92-0248 (909) 624-1665 (800)824-3353 The results on the following page(s) indicate that asbestos was detected in 00 of the 09 samples analyzed. PLM0427#0927 Sample #QT -62 Type of material: acoustical ceiling- white Location: interior ceiling of central livingroom Area: approx. 725 total sq. ft. Friable:yes. Results: none detected Sample #QT -63 Type of material: acoustical ceiling- white Location: interior ceiling south master bedroom Area: approx. 725 total sq. ft. Friable:yes Results: none detected Sample #QT -64 Type of material: acoustical ceiling- white Location: interior ceiling of south master bedroom - west side Area: approx. 725 total sq. ft. Friable:yes Results: none detected Sample #QT -65 Type of material: drywall only- white Location: interior west wall of south bedroom Area: throughout interior walls Friable:no Results: none detected Sample #QT -66 Type of material: ceiling drywall Location: interior ceiling of southeast bathroom Area: throughout interior ceilings of bathrooms Friable:no Results: none detected Sample #QT -67 Type of material: stucco- tan (1 rst layer) Location: exterior north wall Area: throughout exterior walls Friable:no Results: none detected Sample #QT -68 Type of material: plaster- grey (2nd layer) Location: behind sample #QT -67 Area: throughout exterior walls Friable:no Results: none detected (2) SCOTT MORMSON & ASSOCIATES P.O. Box 55329 (909) 624-1665 Riverside, California 92517 DOSH 92-0248 (800) 824-3353 PLM0427#0927 Sample #QT -69 Type of material: roof felt Location: exterior southwest roof under clay tiles Area: approx. 2500 total sq. ft. throughout roof Friable:no Results: none detected Sample #QT -70 Type of material: stucco- tan Location: exterior east wall Area: throughout exterior walls Friable:no Results: none detected U Note: All asbestos containing building material(s) 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 renovation of the property. Inspector Scott C. Morrison Certified Asbestos Consultant DOSH#92-0248 Q) May -06-04 01:08pm From -CAROLINA ENVIRONMENTAL CAROUNAETNIRONMENTAL, NC, toy New Edition Court Cary, NC 27511 Phone: (919) 4414413 Fac (919) 4814442 +4811442 T-113 P.02/05 F-548 LABORATORY REPORT ASBESTOS BULK ANALYSIS Client: Scott Morrison & ASSOCiateS CEI Lab Code: A04-3152 31855 Date Palm Dr. Suite 3-507 Received: 04-30-04 Cathedral City, CA 92234 Analyzed: 05-03-04 i Reported: 05-03-04 Analyst: Gary A. Swanson Project: PLM0427#0927 CEI%. CLIENT ID LAS ID HOMOGENEITY DESCRIPTION ASBESTOS QT -62 A257271 ACOU51IC CEILING NO Homogeneous, White, Non-fibrous, Bound 131ND 100% QT -63 A257272 ACOUSTIC CEILING NO Homogeneous, White, Non-fibrous,'Bound BIND 100% QT -64 A257273 ACOUSTIC CEILING NI7 Homogeneous, White, Non-fibrous, Bound BINC 100% QT -65 A257274 DRYWALL NO Homogeneous, White, Fibrous, Bound BIND 98% CELL 2 QT -66 A257275 DRYWALL NO Heterogeneous, White, Brown, Fibrous, Bound BIND 80% CELL 20% QT -67 A257276 STUCCO NO Homogeneous, Tan, Non-fibrous, Bound BIND 100% Q Pago 1 May -06-04 01:09pm From -CAROLINA ENVIRONMENTAL 1 +4811442 T-113 P.03/05 F-548 CAROUNAENVI tONMENTAL,INC_ Project: PLM0427#0927 107 New Ed*c)n Covet, Cary NC 27511 Phone: 919481-1413 Fax: 919.481-1442 Lab Code: A04-3152 CEI HOMOGENEITY DESCRIPTION ASBESTOS CLIENT ID LAB ID QT -68 A257277 PLASTER No Homogeneous, Grey, Non-fibrous, Sound BIND 100% QT -69 A251278 STUCCO NO Homogeneous, Tan, Non-fibrous, Bound BIND 100% Page 2 f � May -06-04 01:09pm From -CAROLINA ENVIRONMENTAL +4811442 T-113 P.04/05 F-548 The following definitions apply to the abbreviations used in the ASBESTOS BULK ANALYSIS REPORT: CHRY =Chrysotile CELL = Cellulose DEER = Debris AMOS = Amosite FBGL = Fibrous Glass BIND = Binder ORGN = or CROC =Crocidolite organics, SILI = Silicates g TREM = Tremolite SYNT = Synthetics GRAV = Gravel WOLL = Wollastonite MAST = Mastic ANTH = Anthophyllite , ACTN =Actinolite CERWL = Ceramic Wool PLAS = Plaster N D = None Detected NTREM = Non-Asbestiform PERL = Pedits NANTH = Nori-Asbestiform Tremolite RUBR =Rubber. Anthophyllite CLIENT: Scott Morrison & Associate's I I PROJECT: PLM0427#0927 CEI LAB cooE: A04-3152 Stereoscopic microscopy and polarized light microscopy coupled with dispersion staining is the analytical technique used for sample identification. The percentage of each component is visually estimated by volume. These results pertain only to the samples analyzed. *The samples were analyzed as submitted by the client and may not be representative of the larger material in question. Unless notified in writing to return samples, Carolina Environmental, Inc. will discard all bulk samples after 30 days.i Many vinyl floor tiles have been manufactured using greater than 1 % asbestos. Often the asbestos was milled to a fiber size below the detection limit of ppoladzed light microscopy. Therefore, a "None Detected" (ND) )adi g on viore nyl floor tale does not necessarily exclude the resence of asbestos. Transmission electron microscopy provides ve form of analysis for vinyl floor tiles. , It is certified by the signature below that Carolina Environmental, Inc. is accredited by the National Voluntary Accreditation Program (NVLAP) for the analysis of asbestos in bulk materials. The accredited test method is EPA / 600 / M4-82 / 020 for the analysis of asbestos in building materials. Procedures described in EPA 1600 / R-93 / 116 have been incorporated where applicable. The detection limit for the method is 0.1% (trace amount). Carolina Environmental, Inc.'s NVLAP accreditation number is #101768-0. This report is not to be used to claim product endorsement by NVLAP or any agency of the U_ S. Government. This report and its contents are only valid when reproduced in full. Dust and soil analyses for asbestos using PLM are not covered under NVLAP accreditation., ftsviMVVED BY Tianbao Bai,,Ph.D. Laboratory Director End of Repot IFrom: Scott Moeriwn & Associates P.0. ]�Oz 55319 Rivenide, CA M17 (760) 313.7743 Ctiuot: �i`�tqli Job 11Tajtl'' L Fal in Results' v Rdi 2quished BY: IIAIlq OF tCUSI0DY To: Carolina Environments% Inc. 107 New Editko Court Cary, NC 27511 (919)491.1413 NVUw Code 101768i CA RLAP �-- -�—S #G L- 3 Fersou 'ial®g Samples- LA Site Address: �o � 7i eceived By: t�,tit.• ( �� • Datblime:_ ` s Ra/ik I I , Ma�fl'ax To: Scott biOnison & Aw Wws, 31359 Date !aim Dr., Ste. 0-507, ity, Csdmdnd C, CA 922341'(760) 3?3-T°T43 ProjecMase XCO' Uva � �i�Pi.Su� it, and VACANCY WALKTHROUGH Any and all personal property left on the project premises located at __ /b� �,TT�� • J� is to be considered abandoned as of !!2j AS EVIDENCE BY SIGNATURE' AND DELIVERY OF KEYS I HEREBY AGREE THAT OCCUPANCY OF THE LISTED AD KESS HAS BEEN ABAKDONED AND THATNO FURTHER ENTRANCE TO THE ABOVE ADDRESS WILL BE MADE. laimant(s) !a - - Claimants) Signature -�— Date REPLACEMENT ADDRESS: All NEW PHOT ON THIS DATE I PERSONALLY INSPECTED THE DISPLACEMENT AT THE ABOVE ADDRESS AFTER THE OCCUPANT HAD MOVED AND FOUND THE PREMISES TO BE IN SATISFACTORY CONDITION AND THAT ALL PERSONAL PROPERTY, EXCEPT FOR TRASH OR DEBRIS PLACED FOR REMOVAL, HAD BEEN REMOVED FROM THE ACQUISITION AREA EXCEPT FOR THE FOLLOWING: elocution Representative Difto 0 There are tenants remaining on this property. This property'h now vacant Cl Abandoned property remains PROPERTY MANAGEMENT Keys given to: }^� S Date:-- ; 1f Received by :X Owhnd,Pacific & CutW int. 07103 notes: A,f:. on site SCOTT MORRISON & ASSOCIATES P.O. Box 55329 31855 Date Palm Drive, Ste. #3-507 Riverside, CA 92517 (909) 624.1665 Cathedral City, CA 92234 (760)323-7743 INVOICE Client: Tom Hartung's Office City of La Quinta Redevelopment P.O. Box 1504 La Quinta, CA 92253 Project: 76-055 Jefferson St.. �b 235 Jefferson St. 76-335 Jefferson St. 76-480 Jefferson St. Inspection dates: April 27 and'April 28, 2004 Date: May 1.0, 2004 Project/ P.O# File name: PLM0427#1226 PLM0427#0927 PLM0428#0928 PLM0428#1529 asbestos inspection/ bulk sampling: 4.single-family homes @ $125.00 ea. _ $500.00 45 total bulk samples for analysis (PLM) @ $20.00 each ='$900.-00 #'-hours of travel time @ $ each = included Total amount due = $1,400.00 Please send payment to: 31855 Date Palm Drive, Ste. #3-007 Cathedral City, CA 92234 Terms: Net 15 days Thank you. APPROVED FOR PAYMENT BY �_ ACCOUNTNO. -�%�O �SS�- .3.2- to DESCRIPTI AM • O. re � �J T T AY 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 BYE RECEIVED r` s POSTMARK ENTERED:BIr NOTIFICATION #' �,.. _. T COMPLETED BY COMPANY EMERY LANDCLEARING PHONE 760/391-5840 1 LORI EMERY V.P. AND GRADING, INC. DATE 5/26/04 CHECK # t"3 2 FEE $118.41 PROJECT # J NOTIFICATION TYPE ORIGINAL REVISION DATES REVISION OTHER (highligh4 CANCELLATION PROJECT TYPE DEMOLITION ORDERED DEMOLITION RENOVATION (rernOVah EMERGENCY REMOVAL PLANNED RENO (annuaq SITE INFORMATION SITE NAME CITY OF LA QUINTA ROAD EXPANSION PROJECT SITE ADDRESS 46-235 JEFFERSON STREET CROSS STREET WESTWARD HO CITY LA QUINTA STATE CA ZIP 92253 COUNTY RIVERSIDE DESCRIBE WORK AND LOCATION DEMOLISH AND REMOVE AND DISPOSE OF HOUSE FOR PROPOSED ROAD EXPANSION BUILDING SIZE (SQ FT) 2,407 NUMBER OF FLOORS 1 BUILDING AGE (YEARS) 16 NUMBER OF DWELLING UNITS 1 TC;;ERCAL HOSPITAL INDUSTRIAL Other OFFICE PUBLIC BLDG. -HOUSE SCHOOL SHIP UNIVICOLLEGE SITE OWNER CITY OF LA QUINTA ADDRESS 78-495 CALLE TAMPICO CITY LA QUINTA STATE CA ZIP 92253 CONTACT MR TOM HARTUNG PHONE 760/777-7019 REQUIRED BUILDING INFORMATION ASBESTOS YES NO PRESENT? ASBESTOS YES NO SURVEY?* ASBESTOS YES NO REMOVED? BUILDING TO BE YES NO DEMOLISHED? PROJECT DATES START 6/1/04 END 6/22/04 WORK SHIFT (dad(, swing, night) ASBESTOS AMOUNT TO BE REMOVED (n square feet) FRIABLE CLASS I CLASS II TOTAL AMOUNT (add row) ASBESTOS REMOVAL FROM SURFACES PIPES COMPONENTS AMOUNT OF EACH TYPE OF ASBESTOS (n square feet) ACOUSTIC CEILING I LINOLEUM INSULATION FIREPROOFING DUCTING STUCCO MASTIC FLOOR TILES (VAT) DRYWALL PLASTER TRANSITS I ROOFING OTHER (de=be) CONTRACTOR INFORMATION CSLB LICENSE# 600283 OSHA REG# AQMD ID# 100435 NAME EMERY LANDCLEARING AND GRADING, INC. ADDRESS P.O. BOX 1009 CITY THERMAL STATE CA ZIP 92274 SITE SUPVR JAMES C. EMERY PHONE 760/7749493 WASTE TRANSPORTER #1 LANDFILL ADDRESS ADDRESS CITY STATE ZIP CITY STATE ZIP * Asbestos survevs are required prior to Demolition and Renovation SCAQMD NOTIFICATION OF DEMOLITION OR ASBESTOS REMOVAL AIL FORM AND FEE TO SCAQMD, ASBESTOS NOTIFICATIONS, FILE # 55641, LOS ANGELES CA 90074-5641 .i' 14 WASTE TRANSPORTER #2 WASTE STORAGE SITE ADDRESS ADDRESS CITY STATE ZIP CITY STATE ZIP ^ C CONTROLS: DESCRIBE WORK PRACTICES AND CONTROLS TO BE USED AT THE RENOVATION AND DEMOLITION SITE. Procedurefl, 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. ASBESTOS DETECTION PROCEDURE: CIRCLE THE PROCEDURES AND ANALYTICAL METHODS USED TO DETERMINE ASBESTOS IN THE BUILDING: Survey, Bulk Sampling, Inspection, PLM, PCM, TEM, Assumed as Asbestos-PACM, Describe Other: FOR DEMOLITIONS GIVE THE COMPANY NAME AND DATES OF THE ASBESTOS REMOVAL: FOR ORDERED DEMOLITION SEND A COPY OF THE ORDER AND GIVE THE AGENCY NAME & PHONE # AUTHORIZING PERSON: MR. TOM HARTUNG TITLE BUILDING AND SAFETY DIRECTOR DATE OF ORDER: 5/17104 DATE ORDERED TO BEGIN: 6/1/04 FOR EMERGENCY ASBESTOS REMOVAL GIVE THE NAME AND PHONE NUMBER OF THE PERSON DECLARINGIAUTHORIZING THE EMERGENCY, DATE AND HOUR OF EMERGENCY AND DESCRIBE THE SUDDEN, UNEXPECTED EVENT: EXPLAIN HOW THE EVENT WOULD CAUSE UNSAFE CONDITIONS, EQUIPMENT DAMAGE OR UNREASONABLE FINANCIAL BURDEN: CONTINGENCY PLAN: DESCRIBE ACTIONS TO BE FOLLOWED IF UNEXPECTED ASBESTOS IS FOUND DURING DEMOLITION OR ASBESTOS MATERIAL BECOME DISTURBED, CRUMBLED, PULVERIZED, OR REDUCED TO POWDER. STOP PROJECT HAVE CERTIFIED ASBESTOS REMOVAL CONTRACTOR REMOVE AND DISPOSE OF. TRAINING CERTIFICATION: I certify that an individual trained 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 aocornplished by this person 'll be available for inspection during normal business hours. /ture Company Name EMERY Print name of owner/operat Si own /. for Tittle of owner/operator Date 5/26/04 LANDCLEARING AND LORI EMERY ` GRADING, INC. VICE PRESIDENT INFORMATION CERTIFICATION: I certify that the above information is correct and I have enclosed any required attachments. Company Name EMERY Print name of owner/operator Signa of owner/ for Tittle of owner/operator Date 5/26104 LANDCLEARING AND LORI EMERY VICE PRESIDENT GRADING, INC. Notifications can not be accepted without the required fee (AQMD Rul 1). 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 $ 331.21 FROM 100 TO 1,000 SQUARE FEET $ 29.52 SPECIAL HANDLING FEE $ 28.17 FROM 1,001 TO 5,000 SQUARE FEET $ 90.24 REVISION OF NOTIFICATION $11.94 FROM 5,001 To 10,000 SQUARE FEET $211.22 RETURNED CHECK CHARGE $ 29.28 MORE THAN 10,000 SQUARE FEET $331.21 CANCELLATION OF NOTIFICATION $ 0.0 DEMOLITION OF LESS THAN 100 SQ FT $ 29.52 ASBESTOS REMOVAL AT owner- $ 29.52 occupied, single -unit dwelling MAIL FORM AND FEE TO: SCAQMD, ASBESTOS NOTIFICATIONS, FILE # 55641, LOS ANGELES CA 900745641 Page 2 of 2 TELEPHONE: (909) 396-2336 FAX: (909) 396-3342 Form REV 20030627 FORMS, INSTRUCTIONS, AND THE RULE 1403 CAN BE OBTAINED FROM AQMD WEB SITE AT HTTP://WWW. AQMD.GOV CHAA&sf1 :.. 1..... 4-A ..4 Imar G rr..r.rC., n.hm nio—nrr Go. r A 0479M A401 ronoi aoa )nnn