0004-169 (DEMO)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
32 330 C21 12/.31/2(
Date � 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).
(' ) 1, 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, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
(,e)- 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 a'1ATS I•�l4ll Policy No. 1242M
(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 provisionl•of Section 3700 of the Labor
Code, J -shall forthwith comply with those pr'ov dons.
Date'%t 1 -1111� �CO Applicant tom* 11✓
Y f � d
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 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. 1. 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.
I
Signature '(O.wner/Agent) Date t1/ t2U
t
} BUILDING PERMIT PERMIT"
DATE�►I j VALUATION LOT E -1.6-9 TRACT
� j
JOB SITE
APN
ADDRESS
43-g32 WANSiPOp
�3u
OWNER
CONTRACTOR / DESIGNER / ENh3INEFR'
:R.C):f3>+RT R DDRB Y
YOUNCV81.,AAD CLEAkt G
6534SM}'�T.1GHr
82.910 BIECKIlcTM D%
POMAND OR 97 206
TIKERMAL CA
9227,44
(760)398,0894 CB1.0 � 09
f
'`
°
USE OF PERMIT
t'
•
.>: EMOIATION OF (1) SINOL.% FAMILY 13WF1,,MING ONLY
«
VALUATION 5,000.0fi LS
EgMIZATRD. C09f OF COXISt=7IRSdc:'7Y0N
�o23i113,iJ�
DEMOLITION FEE 101-000-423-000 $113.00
WYA.-TOTAL. C01v+!«�i UC"T3.O.hTAND PLAK tP", K
$4.5.00
T.ESS PRE -]PAID M.=1
t?0
RECEIPT
DATE
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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIN. Test
Final I I
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
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)
COMMENTS:
,
SOUTH`COAST:AIR;.QUALITY"MANAGEMENT DISTRICT :..:_ ,
NOTIFICATION;OF-DEMOUTION:OR-ASBESTOS-REMOVAL
21865 E. Cooley Drive Diamond Bar CA 91.78541827"39fr2000 h Jlwww: md. v
AQl� OSEONLY SCREEN BY "RECEIVED ,'POSTMARK;: .:ENTERED BY._.._ :, NOTffICATKNi
COMPLETED BY ROCKY 'YOUNG COMPANY = = ~11 ...PHONE?: 0 '398 0854 :
;,...
YOUNG St LAND CLEARING
DATE: 4/10/00t"w. CHECK# 9.399 z
FEES 26.20.& 78.60 P ECT# Demp Robert Darby Hous
NOTIFICATION TYPE OH Dohs ONOna
(high�ght) ' CANCELLATION . _..
PROJECT TYPE ORDERED DEM x Mo _ O vA- fM. (rem641) E acF REMvv Puii�iEo R io (arinoaq i I .
SITEINFORMATION SITE NAME_ Robert•,Darft House -
.rte -�.� - �;S , w' �.: t -.�. ,r- �5t�•f:� G. �.t+ �i , ..
�SfTEADDRESS . s 32- Wzshingtori CRO
N 43 6 Waring:
.. -.,.
CITY ta.Quinta _ ---- ' .STATE CAS,' , : }' '`'°.ZIP` 82253 :COUNTY '
Riverside
`J t /C%'i• i :i'i'i r'. • .. 1
DESCRIBE WORK LOCATION -- •..Area open and: easy..acc.ess..:.tq.,Inan street
s BUILDING SIZE (SO FT) 1, 500. NUMBER OF FLOQf3�S 1 ` ± BUILDING AGE (YEARS). 53 NUMBER OF DWEWNG UNITS
BLDG PRIOR I PRESENT USE ' CWA' RM • . HWi ff-AL ; 110ustRu. Other ' OMM Rox mm SCHOOL SW
f Yi Knight _
'SITE OWNER Robert`R. barb ADDRESS' 6534SE �.
CfTY._ Portland STATE OR ZIP 97206 CONTACT • Rocky Young PHONE760 398-0.854
s ,REQUIRED BUILDING ASBESTOS YES ='' :ASBESTOS'S YESv NO j -.ASBESTOS'. NO ;BUIU)ING;�O BE : S
INFORMATION
-PRESENT? SURVEY?;.' ' .'' • REMOVED? . DEMOLISHED?
- _ __ „�'� e-.4a:a•,id "''S-...__ .:.,...,gym. •,_i _ .. e
PROJECT DATES :7A,- 5P START : F.
t END 4° 27
�(Pm)
YNORKSNI
ASBESTOS AMOUNT TO BE
'TOTAL REMiovEo(add row)
REMOVED (in Square'feet)
777,
W ... ,.._. '
s a
E' ,
COMPONENTSABe810$REMO __• SURFACES PIP .
DESCRIBE TYPE a AMOUNT OF. ACOUSTIC:CEIUNG `;LINOLEUM;'.' INSULATION tii`FIRE PROOFING :.':DUCTING. ;, :STUCCO MAS
ASBESTOS'�... ,. r } : j ,
FLOOR TILES AT) , DRY -WALL PLASTEll TRANSRE
(y .. ._RQOEING • r t OTHER
632630`-. ,.
COKTRACTOR MFORMATION CSLB LICENSE # OSHAREG # 4 '--A OMD ID F .; : • .
NSE YOUNG'S.LAND CLEARING ADDRESS,82=910 Beckman Drive,- M
CRY ,•, STATE•;�A/ i ZIP92274 SITE SUPVR. Rocky Young :.PHONE: -7.60<398=0854.
WASTE TRANSPORTER tH i�J'_ , >
_
•
ADDRESS: ; , .......... ,�
. •,.' .'ADDRESS'
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CRY . ' •STATE + :w . ZIPYat, CITY 4 :STATE. DP
' Rule 1403 and NESHAP Asbestos Notlficatlon Form REV MM 1403*7 j -
�,,; Pege4•'of'2
,Foran, kahcbm W the Rule 1403 can be obtain via FAX -BACK by dWbg.kM s (a(p).396-2550 ar•.th !) AOMD web aft httpJh Ww,agmd.g0v0T to tdchtrnl
jun-lU-2J-L• U4:4nt-
DRAN ENGINEEEING
No. 7066
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AAAzusa, CA 91702 ' .
(626) 334.0719 JOBi 2475-99
AZUSA LAND RECLAMATION (626) 969-1529 Fax
NO
N-HAZARDOUS WASTE DATA FORM
NAME IPA DARBY EVA
P
6534 S.E. RNIGUT, No
' ADDRESS - • � -
rPHONE No. � 7601 346-6674
' POR'i'LANI). OR 97206' ,
CITY, STATE. ZIP - -
cc 4jmftmAr,
0 CONTAINERS: Na
MP BAGS
TANK DU
Z TYPE: ❑ TRUCK ❑ •TRUCK C3 DRUMS ❑ CARTONS ❑ OTHER
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REMQV AL
� CDT ART F ASRF.STOS OENE RATIND PROCESS
IO
} WASTE OESCRIPTN. - PPM% DDMPONENTS OF WASTE
m COMPONENTS OF WASTE J A
Lu (D o CONSTR DEBRIS
MASTIC
A 9 FLOOR TILE
V vm.PYA READINIi.S _
W
C51E vemrA AraN N/A
!PROPERTIES. PN N/A L310,0 0 LtOU1D ❑ SLVOGE C) SLURRY ❑ OTHER
MANDllwO INSTUCTIONS U . F PROPER RESPIRATORY E UIPMENT .
fHE GENERATOR=.TGIRInFIFS THE WASTE AS DrypEo OR POINTED FULL NAME E sI Aru E
NON-HAZARDOUS.
EPA 4 7
No
of B C&LEY ENVIRONMENTAL 2)•ECTI
1. 10. C'AL 0.0020
W NAME - CAR000049064
OC 2
53 W. REE ST 5ERWCE ORDER MO
'g ADDRESS
T 111 BI•_j�i1D . - IPcK Uv DATE L - .
• Y CITY. STATE. ZIP nF 'DO 9741 l �S - 1
Q. 1) %
H NONL No i 9O8 BAA-70l O GATE
T ?)PED OR PRINTED FULL NAM[ 1 SIONAT' E 2)
` �g9 884-7424
)RUCK. UNIT. I.0
' + Eo, C A. D 0 0 9 0 0 7 6 2 6 ,
NAME
AZUSA LAND RECLAMATION NO
P�yMOSAL METHOD ,
OTHfR
1211 W. GL.A STONE STRLEET ❑ LwwDFILL
LyJ T
ADDRESS - - ,-
JAZUSA, CA 91702 —
V CITY. sate. ZIP - -
W '
Q PHONE NO. (626)334-0719 • ° -- --_�
» DATE •,
• TYPED OR PRINTED fULI NAME A SIGNATURE I
TONS f a'
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GEN OLDIIIEW L A • - ,
MANE
RT/CO HWDF NONE • ,
CIO DISCREPANCY - -
White 8 Yelbw
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COPY Pink - GENERATOR COPY Goldenrod TRANSPORTER COPY
....
..----•..................................................:.................................................................... .
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........................................... '
AQMD
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 ORIGINAL TO SCAOMD. ASBESTOS NOTIFICATIONS. FILE #55641, LOS ANGELES. CA 90074-5641
AOMO USE ONLY SCREEN BY RECEIVED POSTMARK ENTERED NOTIFICATION #
BY
A
COMPANY BRICKLEY ENVIRONMENTAL PHONE 909.888.2010
ICOMPLETEDBYc MYRNA '
PROJECT # 2475
DATE 5-24-99. i CHECK* � ���� FEE � S 10.40 . •
i`&,19ma1 )
Revision Oates Revision Other (highlight) Cancellation
NOTIFICATION TYPE ;7
PROJECT TYPE Demolition Ordered Demolition Ftebovation (removal), Emergency Removal Planned Reno (annual}
SITE INFORMATION SIT&NAME VACANT RESIDENCE r j'
15ifEADDRESS 49-692 WASHINGTON
CROSS 5TREET ,FRED WARRING
CI rY LA QUINTA STATE' CA ZIP COUNTY RIVERSIDE
. I
DESCRIBE WORK LOCATION KITCHEN & BATHROOM
RS 1 BUILDING AGE (YEARS) .53 NO. OF DWELLING UNITS
BUILDING SIZE (SO. FT.) 1.500 NUMBER OF FLOO.'1 +
BLGS PRIOR I PRESENT USE Commercial Hospital Industrial `Other Office Public BldgResidence.•' School Ship UnvlColle•3e
• ADDRCSS 6534 S.E. KNIGHT
: Stl C OWNER i
ROBERT DAKBY.
(.iTY PORTLAND STATE OR ZIP 97206 ' CONTACT .JACK DORAN PHONE 760-346-6674
REQUIRED BUILDING ASBESTOS -YES'; NO ASBESTOS. YES, N0` ) ASBESTOS -YES NO BLDG TO BE YES, NO j
INFORMATION PRESENT? SURVEY? REMOVED? DEMOLISHED •
IPROJECT DATES START 6-7-99 ENO 6-7 ^99 WORK SHIFT..;amfpml `.j
MOUNT TO BE FRIABLF. CkASS I CLASS II TOTAL REMOVED (ADD ROW)
A 310 ,. 310
REMOVED (in Square feet)
------ • COMPONENTS
ASBESTOS REMOVED FROM PIPES RACE& �., '
DESCRIBE TYPE & AMOUNT OF ACOUSTIC CEILING LINOLEUM INSUI ATION FIREPROOFING DUCTING STUCCO MASTIC }
155
ASBESTOS (in square feet)
FLOOR TILE (VAT) DRY WAD' , PLASTER TRANSITS ROOFING OTHER Idescubc)
155 -
CONTRACTOR INFORMATION; CSLB LICENSE # 610414 OSHA REG # 49 AOMD ID # 76397 <•
NAME BRICKLEY ENVIRONMENTAL ADDRESS 957 WEST REECE STREET
CITY SAN BERNARDINO STATE CA ZfP 92411 SITE SUPVR LARA / BRICKLEY PHONE g09-988.2010
DARST I GOMEZ I LARGENT
WASTE TRANSPORTER #1 BRICKLEY ENVIRONMENTAL LANDFILL AZUSA LAND RECLAMATION CO.
ADDRESS 957 WEST REECE STREET ADDRESS .201 GLADSTONE AVE
. I
1CIrY SAN BERNARDINO STATE CA _ ZIP 92411 CITY AZUSA STATE CA zip 91702
I
t . page I of 2
Asoestos Demolition I Renovation Notification Form REV 960610
I..................... P
't
SCAQMD N4-IFICATION OF DEMOLITION OR ASBEF7.11S REMOVAL ,
MAIL ORIGINAL TO SC" 1D, ASBESTOS NOTIFICATIONS, FILE !156841; L, ANGELES CA 90074-5641 ,
sTE TRANSPORTER 11112 . ` 'WASTE STORAGE SITE BRICKLEY'ENVIRONMENTAL
,.
ADDRESS a ADDRESS 957 WEST REECE STREET
CITY STATE ZIP CITY SAN BERNARDINO STATE CA ZIP 92411
CONTROLS: DESCRIBE WORK PRACTICES AND CONTROLSTO BE USED At THE RENOVATION AND DEMOLITIONSITE. Procedure\A0z. 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 appolval
p
ASBESTOS DETECTION PROCEDURE: CIRCLE THE PROCEDURES AND ANALYTICAL METHODS USED TO DETERMINE ASBESTOS IN THE
BUILDING. Sulk sampling, Inspection, Survey, PLM, PCM, TEM, Assumed as Asbestos. Describe Other. `POLARIZED LIGHT MICROSCOPY4 ND
DISPERSION STAINING USING NIOSH APPROVED METHOD 07403 GEMS/ INFOTOX i
r
FOR DEMOLITIONS GIVE THE COMPANY NAME AND DATES OF THE ASBESTOS REMOVAL '
r-R ORDERED DEMOLITION SEND A COPY OF THE ORDER AND GIVE THE AGENCY NAME. ;
,'�THOR121NG
PERSON' TITLE
>
DATE OF ORDER: ` DATE ORDERED TO BEGIN:
-
FOR EMERGENCY ASBESTOS REMOVAL GIVE THE NAME AND PHONE NUMBER OF THE PERSON `DECLARING/AUTHORIZING.THE
EMERGENCY, DATE AND HOUR OF EMERGENCY AND DESCRIBE THE SUDDEN, UNEXPECTED EVENT
dEXPLAIN HOW THE EVENT;WOULD CAUSE UNSAFE CONDITIONS, EQUIPMENT DAMAGE OR UNREASONABLE FINANCIAL BURDEN' -
CONTINGENCY PLAN: DESCRIBE ACTIONS AND PROCEDURES TO BE FOLLOWED IF UNEXPECTED ASBESTOSrIS'FOUND DURING
DEMOLITION OR NON-FRIABLE ASBESTOS MATERIAL BECOME CRUMBLED. PULVERIZED, OR-REDUCED TO POWER. REVISED
I
NOTIFICATION LETTERS WILL BE SENT IF / WHEN APPROPRIATE. REMOVAL WILL BE DONE WITHIN STATE, FEDERAL, CAUOSHA, EPA
RULES & REGULATIONS. r
TRAINING CERTIFICATE: 1 Certify that an individual trained in the provisions of the rogulation AOMD Rule 1403 and NESHAP will boon site during
the removal and evidence that the required train_
in' has been. accomplished by IN $et)on will be available for inspection during normal busine
hours.
.if% SECRETARY
' BRICKLEY ENVIRONMENTAL MYRNAZEITS:/ /%./C(.I�Va., �.0 )
Co iioany Name Print name Of owner/operato SSgnpture f owner/opera or. y Title of ownedoperator Date I
s
INFORMATION CERTIFICATION I Certiry that the above mfor ratio gortecl anrLtt�i have�enclosed any required attachments
I
-BRICKLEY ENVIRONMENTAL MYRNA ZEITS �, f �l (r •' k SECRETARY,
Company Name Print name of ownedoperator �gnaliti ownerlpper r Title of owner/operalui Date
Notifications are not accepted without the required asbestos tee (AQM� ule 301). Qc oval of less than 101) square-feet are exempt from notification i and fees. Please make checks payable to "SCAQMD". Fees are per notification, not refundable, and vary according t0 the asbestos amount to be
removed. Fees are as follows:
'ROM 100-r0 1,000 SQUARE FEET $-10.40. %DEMOLITIONS'. S 26.20
I- ROM,1,001 TO 5;000 SQUARE FEET $78.60 - REVISIONS .. S 10.40.
FROM 5.001 TO 10,000 SQUARE FEET $187.50 CANCELLATIONS <. S 00.00 I ,
MORE THAN 10,000 SQUARE FEET $288.30 RETURNED'PROCEDURES4 K 5 PLANS ' $288.30 ,
• � RETURNED CHECK CHARGE S 25.00
ATTENTION: Keep a copy'of your notification: State law requires that you provide a copy of the demolition notification t Building and Safety
before issuance of a demolition permit. For questions call 909.398.2336. For your convenience please mail and do not hand carry. ,
i
r,
MAIL ORIGINAL TO: SCAQMD, ASBESTOS NOTIFICATIONS, FILE 065841; LOS ANGELES CA 90074-5641
TELEPHONE: (909) 396.2336 FAX: (909) 396-3342 FAX BACK FORMS: (909) 396,2560 WEB_ SITE HTTP:IIWW W.AQMD.GOV
- _ pace 2 bf 2-.
Asbestos Demolition! Renovation Notification form REV 980610 '
f
NOTIFICATION.
CAL/OSHA ASBESTOS
BRICKLEV ENVIRONMENTAL
' 957 WESTREECE STREET
`
� - - . • � SAN I)ERNARUINO,,CA 92411 � -• ,
2 TEI.: (909) 988-2010 FAX; (909) 381 3433 {{
' CALK OF INDUSTRIAL REi AT1ONS r LICENSE NO. 610414, `
.DEPT.
UIV. UI OCCUPATIONAL SAF-F.TY & HEALTH ASBESTOS CERT.'A-6005
ADDRESS: SAN BLKNARDiNO DIST, OFFICE DUSK REGISTRATION N49
,
• 464 W. FOURTH 5•fRGFT, SUITF.-332
SAN ULRNARDINO, CA 92401'
DAPI:. 5.24-99 + JOB 0 2475
' u
NAME / ADDRESS OFF MPLOYER: DORAN ENGINEERING
T 74540 MONTE VF•RDE `
s. '
t PALM,SPRINGS, CA 92260
,
ADURFSS OF JOR SIl'E: VACANT SFR r , ,. LOCATION: KITCHEN & RATHROUM'
\.43-632 WASHIN(:'I'ON a, • +
{
"NEAREST CROSS SFRED WARRING - R
STREET:
�• "
o-
-.
` NAME OF CER'FII�IRD SUPERVISOR. Cl•(�NINGCR/GOMF•Z/BKICKI:F.Y;DAKST/I ARGGN
NA`MF OF 1111ALIFIEI) 1'17RSON IN'CHARGL OF AIR MONITORING, LAA WORK AND
-RESPIRATORS: AS•ABOVL AND GLM SERVICES OR CONTRACTED C A.C�! I.H. , • i ` �•.
•-
JOH START DATE: 6-7-99 JOB COMPLETION DATE: 6-7-99
^
ULSCRIBE SCOPE OF JOB AND WORK PRACTICES (Inc. sq. ft.): SCRAPE AND REMOVE WFT IN
_
SGC•fIONS AND DISPOSE OF APPROXIMA'ftL,Y 155 SQ. FT. OF MASTIC & 155 SQ: FT. OF FLOOR *I'ILI:.
ESTIMATED NUMBER OF EMPLUVFES ON JOB: 2 '
t
EVALUATION UP I'OTF-NTIAL FOR EXPOSURE: MINIMAL EXPOSI IRF RLSPIRATORS ANI)
.- •
PRCITC("I'IVf:. CI`.U'i'IIING VI'ORN'fIIlt011(illUL1T PROJL.C'I'r • _ •' r
(.
'I'12ANSPORTED BY: BRICKLEY`ENVIRONMFNPAL
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U.S.E.P.A. # CAI. 000020974
STATE IIAULER #2599 ''
F
AND/OR
_
r - P.O. BOX 7318
w SAN IIERNARDIN(_), CA 92411 � '• � ,
„
` STATP.. HAULER 9373.1
DUMP SITE: AZUSA LAND RECLAMATION CCI,
'
1201 W. GI.ADSTONL•; STREET
AZUSA, CA 91702 f
** CAD009007626
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