9606-099 (DSF)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions
Chapter 9 (commencing with Section 7000) of Division 3 of the Business a
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date ,
4737)283 A C2!
DateStgnature of Contractor-
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractc
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sc
compensation, will do the work, and the structure is not intended or offered
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licens
contractors to construct the project (Sec. 7044, Business & Professions
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 declaratior
( ) I have and will maintain a certificate of consent to self -insure for worke
compensation, as provided for by Section 3700 of the Labor Code, for tl
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required
Section 3700 of the Labor Code, for the performance of the work for which If
permit is issued. My workers' compensation insurance carrier & policy no. ai
Carrier 00,1130q AC)NXI CMA Policy No. N1 C-341)*101r
(This section need not be completed if the permit valuation is for $100.00 or les
() I certify that in the performance of the work for which this permit is issue
I shall not employ any person in anymanner so as to become subject to tl
workers' compensation laws of California, and agree that if I should becon
subject to the workers' compensation provisions of Section 3700 of "the Lab
Code, I shall forthwith comply with those provisions.
Date: ,`. ; \ , Applicant 'A <
Warning: Failure to secure Workers' Compensation coverage'is unlawful al
shall subject an employer to criminal penalties and civil fines up to $100,000,'
addition to the cost of compensation, damages as provided for in Section 371
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safe
for a permit subject to the conditions and restrictions set forth on. h
application.
1. Each person upon whose behalf this application is made & each person
whose request and for whose benefit work is performed under or pursuant
any permit issued as a result of this applicaton agrees to, & shall, indemni
& hold harmless the City of La Quinta, its officers, agents and employee
2. Any permit issued as a result of this application becomes null and void
work is not commenced within 180 days from date of issuance of 'su(
permit, or cessation of work for 180 days will subject permit to cancellatio
I certify that I have read this application and state that the above information
correct. I agree to comply with all City, and State laws relating ,to the, buildir
construction, and hereby authorize representatives of this City to enter, upc
the above-mentioned property for inspection purposes.
Sinnatura lrlwnor/Onantl n to k '
of
BUILDING PERMIT PERMIT# CONTROL#
nd �J606-€ 99 3531
DATE VALUATION LOT TRACT
611,9/96 to'go.®f)
JOB SITE APN
ADDRESS 452 J11EIFFIAMS N 54.
OWNER CONTRACTOR / DESIGNER / ENGINEER
N1111 . t17�;A(s. 4'4'AI: D14 -OP fj�dC.
is : 8317511 AVE, 50
IND10 CA. 92201
)le
15.86
;or {61.1i75.5g$r�. Cf3l..3f
USE OF PERMIT
ed
tls DENbi.OU11ON
DrIN40111')'ION O1' ti X1.8TfNO Nll L0rN0, mwt3C.iTioN .1v1L1:!`f' GC>mmv wrviipm_ to
— tlf{.1ttI.A'€'it'+11:3.
MOST RRWA'1'}<.82fDEr.F 'NW- .Y.
Is:
rs'(X,'1rt'1'taAC3'.A1Vi0UN'.f' 1(1,1)i)0.00 L::
ie
by
lis
ENT MATED C(3ST Off' CONSTRUCTION
P.E.RMIT FEE SUMMARY
d, t?I�3C3ITIO3�t_1M, 101-000-123-000S450)
ie
ie
or
id
in--
)6
ns
ty
is
atto
N ,,,UD -TOT-, L CON6"TIZU(I'ION A.NO f i.l CH CK. $45.011
S. — L,ESS . PRH,PAID F.8L5 ��.GO
if
n.
is JUN71
.� i"199'61
.
Ru -
RECEIPT 9By DATE FINALED INSPECTOR
'1�1- - f1r�1,,m.�l;����,��I����I.frMrf �MFr4'.��I�e�ll�l�F;'Ja��'���;.T�.!-�.�'"��v���;fin!'�i1_'�.r�1,F���rYr�'i�r1•'r.�;ff�a�Y�.�11,P���;Pr�riy���-b�w'Yr.��
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
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls,
Party Wall insulation
Condensate Lines
Party Wail 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:•
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)
SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT
NOTIFICATION OF DEMOLITION OR ASBESTOS REMOVAL
21865 E. Copley DM, Diamond Bar, CA 91765-4182 (909) 396-2000
SITE. INFORMATION SITE NAME D U S e -
SITE ADDRESS .J
CITY STATE ZIP �3 COUNTY Tu e
DESCRIBE WORK LOCATION
BUILDING SIZE (So FT) 3s O d ' ' NUMBER OF FLOORS ')- BUILDING AGE M'aS@d NUMBER OF DWELLING UNITS r
PRESENT USE
Cain HosarK IwustrfK Mous OFFpummjrRESDEMM Som SHs• ACMT
PRIOR USE
CMSWMK HOSMAL bMT. W mous OMM pd= RM R Saga . SOW UNnnCauFc VAQW
SITE OWNER N ea ADDRESS
CITY
REQUIRED BUILDING ASBESTOS (OYES NO ASBESTOS YNO ASBESTOS YES NO BUILDING TO BE �/ NO
INFORMATION PRESENT?
SURVEY? REMOVED? DEMOLISHED?
i
PROJECT DATES
START �_�i cl, cJ� END�i)l !o l et q (,WORK SHIFT (a)x+'
REMOVAL DATES
START END WORK SHIFT (amlpm)
ASBESTOS AMOUNT TO BE
FRIABLE
CLASS I
REMOVED (in square feet)
CLASS II
TOTAL REMOYED(add rove
ASBESTOS REMOVED FROM'
SURFACES PIPES COMPONENTS
DESCRIBE THE MATERIALS ACOUSTIC CEILING LINOLEUM INSULATION FIRE PROOFING DUCTING ROOFING MASTIC
FLOOR TILES (VAT) DRY WALL PLASTER TRANSITE OTHER (describe)
CONTRACTOR INFORMATION CUB LICENSE N . ' OSHA REG # AOMD ID
NAMEem O U n 6 ti i Teal _ h Ci ADDRESS
CITY STATE ZlPgaao SITE SUPVRtu�c I
�e m' PHONE(
S?
WASTE TRANSPORTER 91 LANDFILL
ADDRESS
ADDRESS
CITY STATE ZIP
CITY STATE ap
.. Rule 1403 and NESHAP Asbestos Notification Fam REV 960601:SV
Page 1 of 2
NJ
SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT ,,A,'-. ; •. � ; ' 4
NOTIFICATION OF DEMOUTION OR ASaMras RENAL4., M1.
21N5 E 0{�,�.J DT�e NnoW Sar CA 91713.5.4182 396-240Q '
,9..s�i_..r.si's+zM19f�..w��auVi'�i� _-- -_
L:
~Rule 1403 and NESWIP Ad esW Nobfiicatian Fum REV 9606tI1:SV
:.jQ{ yt- .: .:..:,i ..:�: :. ,.. :....: '. f.. r:. ....,i �..... :: :.:.\, :?:'.'Ti:S:'�i%�'s ., �!lrl��'��• i•'!:!¢^:;!�.!QS ..'a'll'.r ra}\� vaP ��i•'�,,C ..tf�il,:gyn'�:1
♦.!:P,'ta;. ..- •V
��it,T•: :� r
..,y I. 4.• Ir
...... .... ..!:...:..:...:.: :...:..S.TS::i.21S::f:f::: •.:o tt :..jb:.i :. 'f... -..,.+n ... t U 'r R �� .•:y�•)i:'i: �.. tri.
COMPLETED BY Tanen Stokes COMPANY Constr, , PWNE (•9091 795•-086t�i
y Quantum •z ':�
? T'
DATA: 06/17/95 CHECK# 111 X$10,24 PROJECT# CA0617
NOTIFICATION TAPE ORIGINALXXX REVISION DAT. REVISION OTHER �Lx r} CANCE11ATION A
PiiQ1I`CT TYPE DI �iOLITION ORDERED DEMOLITION RENOVATION ¢ 6VI Q�tE 01MY MIO 4 RENO yx
SITE INFORMATION SITENAME Vacant Residence'- Scheduled Demo
i
SITEADDRESS 50462 Jefferson Street
CITY LaQuinta r ZIP 92253 COUNTY Riverside
DESCRIBEWORK LOCATION Interior 'r. ..._
-4-
BUILDING SIZE (&Q Fry 1200 0 •:: , ;� ,DORS 1 BUILDING AGE Tv -*M)40+ NUMBER Oi= DY'i!ELUNG UNITS N/A
PRES>:NT USE Carte Idos�r� Iyy I11J11OVS Ori Pt�tcEt9cr S�q? � yX
PRIOR USE Capt. H wffAL INDUSTfuk �,s Omm PLRxatr, R�Ce Sw l>wxtuL e VACW
t
SITE {iWNER Mr. Neal Waldrop �t ADI SS
CONTACT Demo Unlimited p"E 619•-775-5884 '.�
"OUIRED BUILDING ASBESTOS YES NO [ASBESTOS YES NO ASBESTOS YES No BUMM TO BE YES NO
ATION PRI=SENT7 XXXX SURVEY? XXX REMOVED? XXX DEMOLISHE D?
PRO.IECT DArVs START EM WOW SHIFT (ar *n)
iFAOVALDATES START 06/30/96 END 07/02/96 W e jj i )B:Ot 5:00PM
ASBESTOS AMOUNT TO BE FRIABLE CLASS I CLASS I!F anti i .
REMOVED In square lest) � 485 485
ASBESTOS 'ItEbk ED FROM SURFACES 480 %^ PIKS 5 �. COMPON!» 3 -
::.. i � .. y,qn ti � a,
DESCRIBE THE 1AATFRIAI.S ACOUSTIC CEILING UNOL UM INSULATION ' FIRE PROOFWG ; DUCTING.-, , .: ,, ROOFING i MASTIC
I knlyS (VAS "Ry WALL PLASTER
OTHER (dB.SC►ibe)
ON CSLB LICENSE N 6698900OOSHA RSG # 518
CONTRACTOR INFORMATION •.
AQAAD IID � I'i•? r r`,�: ' !+ ' . ,
NAME Quantum Construction ADDRESS 32147 Durla' p Blvd . ,H
Suite..
CITY Yucaipa STATECA ZIP 92399 SITESUPVR David Vogel PHONS09--79.5-0866
WASTE TRAINSPORTER #1 BDC LANDFILL 'BF
AI SS 166 South Ayon ADDRESS 1201 West Gladstone
CITY Azusa STATE CAI ZIP
rj
TRANSPORM 42 N A
WASTESTORAMUM N/A
rAaDit►OSSADDRESS
Grry STATE ZIP
CITY STATE
CONTROLS, DESCRIBE WORK PRACTICES AM CWROLS To BE USED AT THE DEMOLITION AND RENOVATION Srtg'i�
I I i
WORK, INDICATE MU 14M PROCIEDUIRE 0 1, 2,3.4 OR 5 OR COM81NATIONS OF PROCEOMS USB.'FOR PROCMMS 4 AND 6, SLUMBuff.-
FOR AOMD PRIOR APPROVAL. PROCEDURE t I and 3
ASBESTOS DETECTION PROCEDURE: DESCRIBE THE METHODS AND PROCEDURES UM To DETERMINE NetHER A&WSTOS 18 PRESENT AT
THE 3RIE, 114MLIUMTHEAPIALYTICALMEOPOW. Polarized Light flicr'oscopy; as per 40CFR'Pftrt 763.10
appendix A, subpait F and 40 CFR part 763, Section 1
FOR ORDERED DEMOLITION SEND A COPY OF THE ORDER AND GIVE THE AGENCY NAME
AUTHORIZI14G PERSON: TITLE
DATE OF ORDER DATE ORDERED TO BEGM: fit,
FOR EMERGENCY ASBESTOS RBIOVAL ONE THE NAMS AND NiONE NUMBER OF THE PMOIR DEQARWWAHHORONG . ;8KNV9MjCDtDA
AND HOUR OF ENIGRGENCY AND DESCRIBE 7M S' SUIDM. UNEXPECTED EVENT:
IC In LIV, 7100
EXPLAIN HOW THE EVENT WOULD CAUSE UNSAFE CONDMONS. EQUIPMENT DAMAGE OR UNREASONABLE FINANCIAL KJRDEW
CONTINGENCY PLAN: DESCRIBE ACTIONS AND PROCEDURES TO 8E FOLLOWED IF UNDO* TED IS FW0 MRW 0MVUt=,0R NMiF�41 4
ASBESTOS MATERIAL BECOME CRUMBLED, PLILVERM, OR RMX;ED TO PUNDER
Immediately apply amended water and contain.
TRAININOCERTIFICATM, I CERTIFY THAT AN INDIVIDUAL TRAND N THE PROMMM OF RE<AAATM AMO MU 143 AND NESNAP WEI BE ON4171E+b 044
THE REMOVAL AND EVIDENCE THAT THE REQUIRED TRAINNG HAS BEEN AOCOWPLMIED BY TAUS PgtM WILL WAVALAME FOR WW" ULRMW=ft--�-
SWINESS HOURS.
PRINT NAME OF OWNEWOPERATORTammy Stokes SIGN AnK OF OW14MOPERAT6l� - DATE06/1096144":
INFORMATION CE UMCATION: I CERTIFY THAT THE AaDVE IW-ORMATK)N 13 CORRECT AND I PAVE ENCLOSED ANY REWIRED A,
PPJNT NAME OF OWiMVOPERATOR Tammy S' SIGNATURE OF OWIERIOPERAT�R-�
tokes
J
NOTIFICATIONS ARE NOT A0CEF= WITHOUT THE REMRIED ASBESTOS FEE KW Rule 30i}-.FEM-OVALLES.4 f
EXEMPT FROM NOTIFICATION AND FEES.' PLEASE MAKE CWA PAYABLE TO WOW. FEES . AREPER''
VARY ACCORDING TO THE ASBESTOS AMOUNT TO BE REMOVED. FEES ARE AS FOLLOWS:
vu
FROM 100 TO 1.000 SQUARE FEET S 1024 DEMOLMONS
FROM 1,001 TO 5.000 SOLUM FEET $76.81
FROM 5,001 TO 10,= SQUARE FEET $17920
MORE THAN 110,000 SQUARE FEET PROCEDLIPE A OR 6 K0�-'*
NOTE: STATE LAW FMIJ03 TP AT YOU OW A COPY OF DENWnN ODTMUTKM TO YOUR LOM 9KMG AND SAFE1Y
-,%,,
MAIL ORIGINAL TO: SCAQMD, RULE 1403 ASBESTOS NOTIFICATIONS, P.O. BOX 4K M40M 1*.?
TELEPHONE:" 39&= FAX 396334
NO NF-SW--"A*--fti N*ftabonF*Tn F;EV%6R!t:S'-;