0108-357 (DSF)LICENSED CONTRACTOR 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
.Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date Cly? .t 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 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, Es provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
y^(„t) 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.
(1404DID WAT'a.1%
(This section need not be completed if the permit valuation is for $100.00 or Ips,.;).
( ) 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 orkers' compensation provssions of Section 3700 of the Labor
Code, I shall �f 4trthth comply with those provisions. IDate: Applicant
"'11Uar`ning: Fai ure to; secure Workers' Compensation coverag :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 fob inspectiogrpurposes. ^
[[
Signature (Owner/Agent) _ yl, Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOTS. TRACT f
JOB SITE
ADDRESS
OWNER
0-2420
PALM IYESEPRX CA 92260
USE OF PERMIT
APN
CONTRACTOR/DESIGNER/
26600 110PTEM, ROAD
IND10 T 1�� CA 42:41.
C16Q)3454746 (T1 11A 19
'11E;t LIL1T1014 OF BUIL NO (HCIU MrIT 7 IrARF, tAROUINl:D
VALUATION
23,000.00 ILI
x5ricmiff#11) COS7 0111 OatiJd.41iAT.l.Saicyrfh./F.l. yi.7VV�=il47
FE"'k” Kilf IMF, SUMMARY
1JOS PIRE-PND PM $6.00
-ina L uamr DuE now &Ism
U AUG 31 2001 1UV
CITY OF LA QUINTA
FINANCE DEPT.
;RECEIPT DATEr 1 BY, DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
- 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 Wail Insulation
Condensate Lines
Party Wali 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 Plbg. 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:
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)
07/24/2001 12:19 5625946290 ENVIROCON PAGE 02
SOUTH COAST AIR 61UALITY MANAGEMENT D*TI1 = (SCAGMD)
NOTIFICATION OF DEMOLITION AND ASSEST03 REMOVAL
21865 E. COPLEY DRIVE, DIAMOND BAR CA 91765.4182 (909) 388-2000
AQMD USE ONLY l SCREEN BY: mcal D POSTMARK ENTERED BY NOTIFICATION S
COMPLETED BY: Renee' Crossland COMPANY: ENVIROCON INC. PHONE: (562) 799.7015
DATE 07/19/01 CMECx a 12260 PEE f 85.47 PROIECTV 01-1527
NOTIFICATION TYPE ORIGINAL REVISION DATES REVISION OTHER (HIGHLIGHT) CANCELLATION
PROJECT TYPE Demolition Ordered Demo RENOVATION Emergency Removal Planned Reno
SITE INFORMATION SITE NAME: Residence.
Site Address: 50400 Jefferson St.
crm La Quints STATE CA zw: 92253 couNTY: Riverside
DESCRIBE WORK LocATtow Living rrom
BUILDING SIZE 2,000 NUMBER OF FLOORS 1 BUILDING AGE 45 NUMBER OF DWELLING UNITS 2
PRESENT USE; COMMERCIAL HOSWAL INOVSMAL OTMOR OFFICE PUBLIC SLIM mouse SCHOOL uNW/Cou.Ece
SITE OWNER: Tool Brothers, Inc. ADDREss: 50400 Jefferson St.
CITY: La Quinta STATE: CA ZIP: 92253 CONTACT: Ms. Amy Donegan PHONE (760) 674-969!
REQUIRED OUILDIN ASBESTOS YES NO ASSESTpS YES NO j ASBESTOS YES NO j BUILDING TO YES NO
INFORMATION PRESENT 7 SURVEY 7 ; REMOVED? BE DEMOLISHED 7
REMOVAL DATES START 08/01/01 IND 08/05/01 WORK SHIFT (AM/FM) 7 - 3
ASBESTOS AMOUNT TO BE FRIABLE CLASS 1 CLASS II i TOTAL REMOVED (AOL) ROW
REMOVED (IN SQUARE FEET) : 1,800 I . 0 i 0 I 1,800
ASBESTOS REMOVED FROM SURFACES. PIPES COMPONENTS
DESCRIBE TYPE & AMOUNT ; ACOUSTIC CEILING, LINOLEUM INSULATION FIRE PROOFING DUCTING ; STUCCO MASTIC
OF ASBESTOS ; 1,800
FLOOR TILES (VAT) DRY WALL I PLASTER j TRANSITE I ROOFING j OTHER (DESCRIBE)
CONTRACTOR INFORMATION CSLB LICENSE N 608700 OSHA REO A 349 AQMD IDA 088523
NAME Envirocon Inc. ALWRESS 11022 Winners Circle 0200
CITY Los Alamitos STATE: CA zip: 90720 SITE SUPYR M. Guevara PHONE (562) 799-701;
WASTE TRANSPORTER AI Envirocon Inc. LANDFILL La Paz County Landfill
ADDRESS: 11022 Winners Circle, Suite 200 ADDRESS 26999 Highway 95, Mile Post 128
crrY: Los Alamitos STATE: CA zip: 90720 I cITY Parker STATE AZ zip 85344 -
Asbestos DsmdiftnMenovatlon Notiflcation Form REV 200810 PVQq 1 of 2
6�,l 3I6 q,a s1 W"
07/24/2001 12:19 5625946290 ENVT_ROCON PAGE 03
WASTE TRANSPORTER 42:
S cit R Services, Inc.
ADDRESS: 19172 Stewart St.
CITY: Huntington Beach STATE:
WASTE STORAGE SATE:
� r •Ta.
CA ZIP: 926431 CITY:
STATE: ZIP:
CONTROLS: DESCRIBE WORK PRACTICES AND CONTROLS TO BE USED AT THE DEMOU11ON AND RENOVATION SITE, Procedure 111,2,3,4,5 o
1
For asbestos removals circle tits combination of Rule 1403 procedures used. Procedure 4 and S submit plans for ACM prior approval.
ASBESTOS DETECTION PROCEDURE: Circle IN prooedums and analytical methods used to detenlMne asbeelos In the building:
Bulk Sampling, Inspection. Surrey, PLM. PCM, TEM, Assumed as Asbestos, Descrtba Other:
Procedure used to determine asbestos: PLM
FOR ORDERED BEMOUTION SEND A COPY OF THE ORDER AND GIVE THE AGENCY NAME;-
AUTHORIZING
AME:AUTHORIZING PERSON: TITLE:
DATE OF ORDER: DATE ORDERED TO BEGIN:
FOR EMERGENCY ASBESTOS REMOVAL GIVE THE NAME & PHONE 0 OF THE PERSON OECLARING/AUTHORIZING 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: DESCRIeE ACTIONS AND PROCEDURU TO DE FOLLOWED IF UNEXPEGTFD ASBESTOS 13 FOUND DURING DEMOLITION OR NO"RIA&F
ASBESTOS MATERIAL aECOME4 CRUMBLED, PULVERIZED. OR REDUCED TO POWDER.
ISOLATE WORK AREA. INSTITUTE FIBER CONTROL MEASURES.
NOTIFY BUILDING OWNER, PROCEED AS DIRECTED INCLUDING REVISED NOTIFICATIONS.
TRAINING CERTIFICATION: I certify that an Individual trained in the provisions of reVedon AQMD Rule 1403 and NESHAP WHI be on site during the
(onmval and evidence that the required training has en d y INS perso II be available for Inspection during normal business hours.
Envirocon Inc. Harry LiBr Vice President 07/19/01
Company Namne e Noof owner Signature of owner Title of owner Date
INFORMATION CERTIFICATION I CERTIFY THAT THEW."a,
Ig RFCTANO 1 YE E.4CLOSFO ANY REQUIRED ATTACHMENTS.
15
Envirocon Inc. Hart' LiBr Vice President 07/19!01
Company Namo None of ownerof owner Tide of owner DATE
Notifications are not accepted without the required asbestos fee (AQMD RULE 301). Removals of less than 100 square feet are exempt from notification to
Please make WOOS payable to 'SCAOMD'. Fees ars per nothIcation, not refundable, and very according to the asbGS103 amount to be removed.
Fees are as follows: - 1 PROCEDURE 4 OR 5 PLAN $313.72
FROM 100 TO 1,000 SQUARE FEET $ 27.96 SPECIAL HANDLING FEE $ 26.66
FROM 1,001 TO 5,000 SQUARE FEET $ 33.47 REVISION OF NOTIFICATION $ 11.31
FROM 5,001 TO 10,000 SQUARE FEET $200.07 RETURNED CHECK CHARGE $ 27.74
MORE THAN 10,000 SQUARE FEET $313.72 CANCELLATION OF NOTIFICATION $ 0.00
.DEMOLITION OF LESS THAN 100 SQ FT $ 27.96 _ «RESIDENTIAL ASBESTOS REMOVAL $27_96
NOTE: auto I" r""" got you provlda a 0epy of the dweothlon nouncatton to building and safety boon Masan* Of a damdMeon perywt For q,wtw w can +toe} 3ea-Ys3s
MAIL TO: SCAQMD, ASBESTOS NOTIFICATIONS, FILE #55641, LOS ANGELES, CA 90074-564
TELEPHONE: (909) 396 - 2336 FAX: (909) 396-3342
Rule 1 103 end N"HAP Aebeaw Nosticawn Fora+ REV "0610 Page 2 of 2
07/24/2001 12:19 5625946290 ENVIROCON PAGE 01
' ENVIROCON Inc.
Environmental Contractors
FAX COVER SHEET
FAX NUMBER: ILD - 3 L4 9- got t7c-�
To: .(L R 1 p . From: �i LQ_
Company: Date:
Tei. ir#: ( )
Mes
r
No. of pages including cover sheet:,.,
Re:
The original of this transmission will be sent to you by:
O U. S. Mail O Federal Express C3't✓1se Fax As Original C Mend Delivery
If you did not receive the number of pages indicated above, or have any questions,
please call.
If you are not the intended recipient of this transmission, please call the telephone
number below or return via U.S. Mail. Thank you.
e.%"FV4 srennnaenMt.Sm
It 022 Winners Circle #200, Los Alamitos, California 90720 • Contractor's License 0608700
(562) 799-7015 • (800) 499-9919 • FAX (562) 594-6290
http:\\wwlw.eriviroconinc.com
SOUTH COAST AIR QUAL MANAGEMENT DISTRICT
NOTIFICATION OF DEMOLITION OR ASBESTOS REMOVAL
21865 E Copley Drive, Diamond Bar, CA 91765-4182 (909) 396-2000 .
MAW FnM MM FEE TO SCAOMD. ASBESTOS NOTIRCATIIOMS, RLE # 59641, LOS ANGELES CA 900745641
TION #
AOl�:USEONLY POSTMARK ENTERED BY NOT�K'.11
COMPLETED BY(: ivy (� COMPANY �.11i1A r� PHONE
DATE -lb
U + CHECK # • t , %� FEE $ U5 ,�� PROJECT #
NOTFICATION TYPE
REvsm DATES REY=N OTHER (hkj fthq CANCELLATrON
PROJECT TYPE
ORWM DEMWnON RENOVATION (MffVV* EmBtGeCV REMOVAL PLANNED RENO (affiYA
SITE MIFORMATION
SITE NAME J
SITE ADDRESS - �Co -k�j 5 t s �- CROSS STREET ltd 56
STATE ZIP COUNTY
DESCRIBE WORK AND LOCATION L
BUILDING SIZE (SO Fr) ` NUMBER OF FLOORS BUILDING AGE (YEARS) ER OF DWELLING UNITS
BLDG PRIORI PRESENT USE
Cawed Hoswrnl N+oMwM Otlrer Pueuc =S!2 S0100 SHP UMwCa am
SITE OWNER' f -n ADDRESS _ IkOU J Q �• ' '
CITY �p �v, n1� STATE In ZIP q pa -S CONTACT u Un PHONE 1�6 L
REQUIRED BUlLDING
INFORMATION
ASBESTOS E$ NO
PRESENT?
ASBESTOS NO
SURVEY? '
ASBESTOS ES NO
REMOVED?
BUILDING TO BE ES NO
DEMOLISHED?
PROJECT DATES
START
O t END 1, WORK SHI ay,' ng, night)
ASBESTOS AMOUNT TO BE
REMOVED (n square feet)
FRIABLE
CLASS 1
CLASS Il
TOTAL AMOUNT (add row)
ASBESTOS REMOVAL FROM
SURFACES PIPES COMPONENTS
AMOUNT OF EACH TYPE OF
ASBESTOS (m square feet)
ACOUSTIC CEILING
I LINOLEUM
I INSULATION
FIRE PROOFING
DUCTING
STUCCO
MASTIC
FLOOR TILES (VAT)
DRY WALL
PLASTER
I TRANSrrE
ROOFING
OTHER
()
CONTRACTOR INFORMATION
CSLB LICENSE # OSHA REG # AQMD ID #
NAME v ADDRESS , V
CITY o� i G�1�)�1`J STATE( DP "I a� ?� SITE SUPVR �, PHONE rl(oo
WASTE TRANSPORTER #1
LANDFILL
ADDRESS
ADDRESS
CITY STATE DP
CITY STATE ZIP
* Asbestos surveys are required prior to Demolition and Renovation
SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT
NOTIFICATION OF DEMOLITION OR ASBESTOS REMOVAL
21865 E Copley Drive, Diamond Bar, CA 91765.4182 (909) 396-2000
MAIL FORM AND FEE TO SCAQMD, ASBESTOS NOTIFICATIONS, FILE # 55641, LOS ANGELES CA 900746641
AQMD USE ONLY FEN BY '= ,.: ;: RECEIVED
COMPLETED BY W ( I :E wI( COMPANY � �
POSTMARK ENTERED BY NOTIFICATION #
PHONE 9 ( o 3 y S- if?Yf►
DATE V�(1 0 1 CHECK # FEE $ C 3 PROJECT #
'ITYPE
NOTIFICATION
ORrwAL REVISION DATES
REVISION OTHER (highlight) CANCELLATION
PROJECT TYPE
ION ORDERED DEMOLITION
RENOVATION (removal) EMERGENCY REMOVAL PLANNED RENO (annual)
SITE INFORMATION
SITE NAME
SITE ADDRESS M _"b on CROSS STREET{,
CITY RulV1%r- STATE
ZIP C�� iS3 COUNTYll�,F;Q�+
DESCRIBE WORK AND LOCATION
BUILDING SIZE (SOFT) �r NUMBER OF FLOORS
BUILDING AGE (YEARS) q NUMBER OF DWELLING UNITS,
BLDG PRIORI PRESENT USE
COMMERCIAL HosPrrAL INDUSTRIAL
Odw OFFICE PUBLIC BLDG. OUSE SCHOOL SHIP UNIV/COLLEGE
SITE OWNER 'rb� r0 S G •
ADDRESS p)'j) .. ypo (1 ff�� Gln
✓M 1 �"
CITY
"C STATE /� ZIP S
CONTACT PHONE
REQUIRED BUILDING
INFORMATION
ASBEST'O'S` YES <�q ASBESTOS ES NO
PRESENT? SURVEY? •
ASBESTOS NO
REMOVED?
BUILDING TO BE ES NO
DEMOLISHED?
PROJECT DATES
START !� 1
END 9 O J 01 WORK SHIFT&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 (in square feet)
ACOUSTIC CEILING
I LINOLEUM
INSULATION
FIRE PROOFING
DUCTING
STUCCO
MASTIC
FLOOR TILES (VAT)
DRY WALL
PLASTER
TRANSITE
ROOFING
OTHER
(describe)
CONTRACTOR INFORMATION
CSLB LICENSE # �� OSHA REG # AQMD ID # l U p 3 57
NAME ��n d �,�,
ADDRESS O O. O x 3 8
CITY war (� ���c)STA7E _ ZIP -� � , SITE SUPVR Olm�o PHONE
WASTE TRANSPORTER #1
LANDFILL
ADDRESS
ADDRESS
CITY STATE ZIP
CITY STATE ZIP
/I
SCAQMD NOTIFICATION OF DEMOLITION OR ASBESTOS REMOVAL
MAIL ORIGINAL TO SCAQMD, ASBESTOS NOTIFICATIONS, FILE # 55641, LOS ANGELES CA 90074,5641
WASTE TRANSPORTER 02
WASTE STORAGE SITE
ADDRESS
ADDRESS
CITY STATE ZIP
CITY STATE ZIP
CONTROLS: DESCRIBE WORK PRACTICES AND CONTROLS TO BE USED AT THE RENOVATION AND DEMOLITION SITE. Procedure # 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 PROCEDE CIRCLE THE PROCEDURES AND ANALYTICAL METHODS USED TO DETERMINE ASBESTOS IN THE BUILDING:
Bulk Sampling, Inspection, Survey CM, TEM, Assumed as Asbestos, 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: TITLE
DATE OF ORDER DATE ORDERED TO BEGIN:
FOR EMERGENCY ASBESTOS REMOVAL GIVE THE NAME AND PHONE NUMBER OF THE PERSON DECLARINGIAUTHORONG 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 AND PROCEDURES TO BE FOLLOWED IF UNEXPECTED ASBESTOS IS FOUND DURING DEMOLITION OR NONFRIABLE
ASBESTOS MATERIAL BECOME CRUMBLED, PULVERIZED, OR REDUCED TO POWDER
--2 30b1 t:0 tl lack PK)P0615 �QlwO COn"Y'
TRAINING CERTIFICATION: I certify that an individual trained in the provisions lation AQMD Rule 1403 and NESHAP W O be on site during the removal and
evidence that the required training has been accomplished by this person will be or' during normal business hours.
� r
�� C - 'vel"/
Company N Print name of ownedoperator Signatu o or Tittle of ownedoperator
INFORMATION CERTIFICATION: I certify that the above information is conedIo/or any required attachments. Q� /
�
(tel � (.G1 � Com' `^'1 (�{� it �Q,r'% (.fJ � d G✓h/I/>. `( z�l / � J
Company Name Print name of ownerloperator Signature Tittle of owner/operator Date
Notifications can not be accepted without the required fee (AQMD Rule 301). 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 $ 302.53
FROM 100 TO 1,000 SQUARE FEET $ 26.96 SPECIAL HANDLING FEE $ 25.73
FROM 1,001 TO 5,000 SQUARE FEET $ 8242 REVISION OF NOTIFICATION $10.91
FROM 5,001 TO 10,000 SQUARE FEET $19293 RETURNED CHECK CHARGE $ 26.75
MORE THAN 10,000 SQUARE FEET $302.53 CANCELLATION OF NOTIFICATION $ 0.0
DEMOLITION OF LESS THAN 100 SQ FT $ 26.96 RESIDENTIAL ASBESTOS REMOVAL ' $ 26.96
— owner -occupied, si e -unit dwelling
ATTENTION: Keep a copy of your notification. Sate law requires that you provide a copy of the demolition notification to Building and Safety before issuance of a
demo tion permk. For questions call 909,IW2336. For your convenience please mail the form and fee and do not hand carry to AQMD.