0111-061 (DSF)LICENSED CONTRACTOR DECLARATION
�l hereby affirm under penalty of perjury that I am licensed under provisions of
IChap3er 9 (commencing with Section 7000) of Division 3 of.the Business and
! "-Professionals Code, and my License is in full force and effect.
License.e # Lic. Class Exp Date
rr}} g�ss
{ Date ^ f r Sigliature 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&RC. 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, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
kI 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.
STATRIPYND 171112819-99
(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.
Date: ,:{., }. 4'1 Applicant-
Warning:
pplicant 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 she 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 applicationbecomes 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/Ageht)'0,',s:'"- `�' i` - m�-- Date I I ` -
BUILDING PERMIT PERMIT#
vEm� VALUATION LOT 0111-061 TRACT
�.Ir�i�s� {dam
JOB SITE
ADDRESS 52s (W CI6'M rA id9:p59J5�
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
52 -:Me, &IAM -3 9
82-9 n : ECIOAA T 1011,
1A QRANTA, C& 92253
TWERIA&I CA 92274
( +i 60)198.0854 CB161' 2801.0
USE OF PERMIT c
ESTE"= Co lS-tA, OA, (1101 �Tp1.6i.LA Ntd10
PREIIIIIArr 1571F. SUMMARY
INF)MOLIT1014YE E 10.1 -000-423-000 443,0D
NOV 0 7 20�
01
C67 YOFLAQUR�A
a RINVANCE �2PPY.
U"AL P1ANS' . FFEE'S 1) 0, Tr NOW
RECEIPT
DATE
if ,SCI
BY f
r
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 Wall Insulation
Condensate Lines
Party Wall 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)
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 BY RECEIVED POSTMARK ENTERED BY NOTIFICATION S
76-1 I
COMP L`'iEDBYy'j,ckY yGt�„ COMPANY /accn S ` ctnc/ C �Q•c,;„ PnONC
DATECHECK # a y FEES 5 , y PROJECT #
NOTIFICATION TYPE
IGINA REVISION DATES REVISION OTHER (highlight) CANCELLATION '
I
PROJECT TYPE
DEMOLITION ORDFR_-D DcMCLITION RENOVATION (rernoval) EMERGENCv REMOVAL PLANNED RENO (annual)
SrTE INFORMATION
SITE NAME 4 �e n 0 u Sa
SITE ADDRESSfr�r 74- CROSS STREET �q</ -. 5 --)-
CITY L a C.; A 14`I STATE ZIP °%�� S 3 COUNTY
DESCRIBE WORK AND LOCATION
BUILDING SIZE (SO FT) ca c NUMBER OF FLOORS ' BUILDING AGE (YEARS) 3 G NUMBER OF DWELLING UNITS J
BLDG PRIOR f PRESENT USE
ComweRCIAL KWITAL INDUSTRIAL Ocher OFFICE PUBLIC BLDG.HOUSE SCHOOL SHIP UNIVCOLLEGE
SITE OWNER .�'�Y Q L(+'n ADDRESS //( * j
CITY STATE ZIP CONTACT �t cr n PHONE
REQUIRED BUILDING
INFORMATION
ASBESTOS ES NO
PRESENT?
ASBESTOS ES NO ASBESTOS Z5 7NUILDING
SURVEY? • REMOVED?
TO BE YE NO
EMOLISHED?
PROJECT DATES
START fl -� 8 .1 G ( END ., 3 _. r WORK SHIF i (day, swing, night) '7-S'
ASBESTOS AMOUNT TO BE
REMOVED (in square feet)
FRIABLE
CLASS I
Ct ASS I!
TOTAL AMOUNT (add row)
ASBESTOS REMOVAL FROM
SURFACES PIPES COMPONENTS
AMOUNT OF EACH TYPE OF
ASBESTOS (in square feet)
ACOUSTIC CEILING
LINOLEUM
INSULATION
FIRE PROOFING
DUCTING
STUCCO
MASTIC
FLOOR TILES (VAT)
DRY WALL
PLASTER
- TRANSITS
ROOFiNG
_ OTHER
(describe)
CONTRACTOR INFORMATION 7
CSLB LICENSE # G 3 ,� 6.3 OSHA REG # AOMD ID #
NAME 1 4 A c S L 4� C lee, r; /1 ADDRESS -D-91C6
CITY l �,� m 4 STATE ZIP SITE SUPVR,�1,?,c l` � yG 4� PHONE 3 y b ,a g S y
WASTE TRANSPORTER #1
LANDFILL
ADDRESS
ADDRESS (cl S
CITY
STATE ZIP
CITY S 5
STATE
ZIP ` 7 y
Asbestos surveys are required prior to Demolition and Renovation
Forms, instructions, and the Rule 1403 can be obtained from AQMD web site http://www.agmd.gov Page 1 of 2 Form REV 200610
SCAQMD NOTIFICATION OF DEMOUTION OR ASBESTOS REMOVAL
MAIL ORIGINAL TO SCAQMD, ASBESTOS NOTIFICATIONS, FILE 1115%41, LOS ANGELES CA 900743641
WASTE TRANSPORTER 92
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.
Ii
For asbestos removals circle the combination of Rule 1403 procedures used. Pure 4 and 5 submit plans for AQMD prior approval.
roced
I
ASBESTOS DETECTION PROCEDURE: CIRCLE THE PROCEDURES AND ANALYTICAL METHODS USED TO DETERMINE ASBESTOS IN THE BUILDING: ;
Bulk Sampling, Inspection, Survey, PLM, PCM, TEM, Assumed as Asbestos, Describe Other.
• 1
FOR DEMOLITIONS GIVE THE COMPANY NAME AND DATES OF THE ASBESTOS REMOVAL i Gh f '`
FOR ORDERED DEMOLITION SEND A COPY OF THE ORDER AND GIVE THE AGENCY NAME & PHONE #
AUTHORIZING PERSON: TITLE I
DATE OF ORDER DATE ORDERED TO BEGIN:
1
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:
i
I
CONTINGENCY PLAN: DESCRIBE ACTIONS AND PROCEDURES TO BE FOLLOWED IF UNEXPECTED ASBESTOS IS FOUND DURING OEMOLrTIONI_g&NONFRIABLE
ASBESTOS MATERIAL BECOME CRUMBLED, PULVERiZI D, OR REDUCED TO POWDER. 5 -F c f w c r w 1 'f-
Qua , Ccivw; fh rj/A3"'a r4// 5'-.19r-111 1L A1-5 2<
TRAfNING 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 accomplished by this person will be available for inspection during normal business hours.
Company Name Print name of owner/operator Signature of owner/operator Tittle of owner/operator Date
WFORMATM CERTIFICATION: I certify that the above information is correct d I have enclosed any required =achments. -
�1;76�0;
Company Name Print name of ownedoperawr Signator Tittte 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 nottkabon and fees.
Please make checks payable to'SCAQMD'. Fees are per notlficatian, not refundable, and vary according to the project sae. Fees are as follows:
DEMOLITION OR ASBESTOS REMOVAL PROCEDURE 4 OR 5 PLAN $ 313.72
FROM 100 TO 1,000 SQUARE FEET $ 27.96 SPECIAL HANDLING FEE $ 26.68 -
FROM 1,001 TO 5,000 SQUARE FEET S 85.47 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 $ 0.0
DEMOLITION OF LESS THAN 100 SQ FT $ 27.96 ASBESTOS REMOVAL AT owner- $ 27.96
occupied, sin "nit dwelling
ATTENTION: XW a copy of your natio sHoon. State law requires that you provide a copy of the demolition notification to Building and Safety before issuance of a
dwriogt cin permit For questions call 909-396.2336. For your convenience please mail the form and fee and do not hand carry to AQMD.
MAIL FORM AND FEE TO: SCAQMD, ASBESTOS NOTIFICATIONS, FILE 9 55641, LOS ANGELES CA 90074.5641 Forth REV 0Pop 2 of 2
TELEPHONE: (909) 3962336 FAX: (909) 396.3341
FORMS, INSTRUCTIONS, AND THE RULE 1403 CAN BE OBTAINED FROM AQMD WEB SITE AT HTTP://V1wW •AQMD-GOV
SCAcmD is wcawd at 21865 E. Copley Drive, Diamond Bar, CA 91765.4182 (909) 396-2000
r
ENVIRONMENTAL
KLEAN-UP
CERTIFICATE OF COMPLETION
THIS IS TO CERTIFY THAT AN ASBESTOS ABATEMENT
PROJECT HAS BEEN COMPLETED IN ACCORDANCE TO
SCAQMD, STATE, & FEDERAL REGULATIONS AT:
Single Family Residence
52250 Jefferson Street
La Quinta, CA 92253
JOB #
EKU-201-148
Removal and disposal of Non -friable asbestos contaiuvng materials (ACM) approx.
450sq/ft brown door tile.
DATE
September 20, 2001
,0 3ry!
JOB NAME
Young's Land Clearing
Julian F. Baden
WITNESSED
Beverley�6 n6
J�
P.0.'Box 2-85 Mira. Loma Ca. 91752
Phone (909) 685-5314
Fax (909) 681-5559
nA3 :Z� ?.00Z/0E/0L
PROPOSAL AND CONTRACT IIIIIIIIIIIIIIIIIIIIII
(NOT FOR HOME IMPROVEMENT)' 7 67775 92565 4
Date: 7-22-01 t9 . TO Jay Baden
(hereinafter "Owner"), Telephone no. ( )
Youn:;,s Land Clearing (hereinafter "Contractor")
propose(s) to furnish all materials and perform all labor necessary to complete the following: [Insert a description of the work to be done and a description of the materials to
be used and the equipment to be used or installed, and state the address of the job site.]
This Contract is for the complete Demolition of one House located at
52-250 Jefferson Street in La Quinta. The work consists of the com]✓lete
removal.of the.Structure, Foundation and Septic system.No Asbautos
related work is included in this Propsal7Contract. Demolition Permits
are included. No Tree removal is includedunless they are in the aay of
the Demolition. Youngs Land Clearing to furnish Certificate of insurnace
namin%SJay,Baden,-dsFAdditional insured, Hold Harmless agreement and
Workers Compensation Certificate. The work should take 5 working days
to complete. Owner to be responsible for Asbestos related work unless
other arrangements are made. R Ic e 7-
Your. -,s Land Clearin•' is expecting too tits o :�in September but as of
rota' an exact time to start is not definite.
All of the above work is to be completed in a substantial and workmanlike manner according to standard practices for the sum of
Ei` bt heb.sand five rseellar. Dollars(s 8, 500.00
Progress payments shall be made as follows:
to the value of
per cent I-%) of all work completed.
The remaining balance of the contract is to be paid within days alter completion.
This proposal is valid until _ _ , and it accepted on or before that date, work will commence approximately on
and will be substantially completed approximately on 9 vpSk i t q d a y s subject to delays caused by acts of God. stormy weather, uncontrollable
labor trouble, or unforeseen contingencies.
Any alteration or deviation from the above specifications, including but not limited to any such alteration or deviation involving additional material and/or labor costs, will be
executed only upon a written order for same, signed by Owner and Contractor, and if there is any charge for such alteration or deviation, the additional charge will be added to
the contract price of this contract.
It any payment is not made when due, Contractor may suspend work on the job until such time as all payments due have been made. A lailure to make payment for a period
in excess of days from the due date shall be deemed a material breach of this contract.
Respectfully submitted,
Name and Registration No. of any Salesperson who solicited or negotiated this
contract:
Name
No
Youa3, s Land Cleari n�i
J-� Name of Contractor ,
By
gnature
82-o10 Beckman Drive
Street Andress
760 398-0854
Tbermal, VA.92274 ( ) -
City State Zip Telephone No.
652620 Contractor's State License No
ACCEPTANCE 1=r�r,:v_ I: r .,sif; ; r 'r L•t
You are hereby authorized to furnish all materials and labor required to complete the work mentioned in-fh sT'I roposal, nor 'W-Nfoii-I-Cwe
agree to pay the contract price mentioned in this Proposal, and according to the terms thereof. I/we have read and agree to the provisions
contained herein, and in any attachments hereto, which are made a part hereof and are described as 'A%kt + y
r- - -
Owner's Name
Sweet Address
City ' State Zip
Business Address Business Phone o
ACCEPTED~ : ;.: �__'.�� - / , . Z&zk%
( ner's Signature) (Da(e)
Contractors are required by law to be licensed and regulated by
the Contractors' State License Board which has jurisdiction to
investigate complaints against contractors if a complaint is filed
within three years of the date of the alleged violation. Any ques-
tions concerning a contractor may be referred to the Registrar,
Contractors' State License Board, P.O. Box 26000, Sacramento,
California 95826.
WOLCOTTS FORM 564NHIO—PROPOSAL AND CONTRACT (NOT FOR HOME IMPROVEMENT( (Quad ser)—Rev 4:93 'See Form 564 lot a Proposal and Contract for Home Im-roveme-: laaaaed) c 1993 WOLCOTTS FORM„ INC
. rT.,:. _ r. deo for- - d•c .. _ .., cn. =a •ry onus Saar) o-,, , o.n,o ,_..... _ _