9807-166 (RER)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
1— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O M License # Lic. Class Exp. Date
LLJ
B 1I/s0r
O r- - Date n Signature of ContractorCID
J U C:) OWNER -BUILDER DECLARATION
Ha 1 hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) . License Law for the following reason:
Z_ ( ) 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).
C0 �O I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner .
O•C\I
CL Q WORKER'S COMPENSATION DECLARATION
p cr I hereby affirm under penalty of perjury one of the following declarations:
Lo O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q U (� I have and will maintain workers' compensation insurance, as required by
Q' Q Section 3700 of the Labor Code, for the performance of the work for which this
d H permit is issued,'My,workers' compensation insurance carrier & policy no. are:
Z Carrier i Policy No.
cb Z) _
S'TAT.E'Ftd'ND 129781J-98
J(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 provisio s9
/Date: —, v Applicant,J: {-
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
w 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 for inspection purposes.
Signature(Owner/Agent) Date r; r'S+
v -, , ze BUILDING
„-
PERMITPERMIT#
DATE VALUATION LOT "07.1" TRACT
�.,f�r;-, S3.r�1��An
JOB SITEI
APN
ADDRESS
46.775NYE►.,S13INGTOK 51T",,k
643-194-012
OWNER r
CONTRACTOR/DESIGNER/ENGINEER
EMMON POLLAP-0
TRIBBLE CONS'T'RUCTION CO., INC.
467175 4VASHIN'G1`UN ST
90.655 AVENUE 43
LA QU1NTA CA 922.53
INDIO Cal 92201
(77K),347-9755 CBL# 5291
USE OF PERMIT
FERE DAMAGM iM F!1-^',I�'/A.1H2: 1E+ :IIA!:`LEC'IMCA,1: ck Hifi 4,.REPLACk.
INSULATION & DRYWALL; REPAIR C3R REPLAC1l WINWWS; PANT
INTERIOR AND MCT 1:1 OR
VALU'K ON 73,000.00 L.S
ONTINIATC, D COST UP 4~`ONIS'TRUCT ON'
73,040.00
PERMIT FU S'UMMARY
PLANC}IECK I'1::1�; 101-000-43.9-318 $336.70
CONS' -RUCTION 101-00"18-000 $518.00
MCHANICAL FU :101-000-421-000 $35.00
ELECTRICALFEF; 101-000-420.000 591.25
PL.UNMING ME 101-000-419-000 $15.00
STRONG MOTION FEE. - ill SID 101.000-241-000 E7.30
A.
SC:WIMAL CONST! UCfION AND PLAN CHECK
� LESS PM -RAID FESS
$0,610
$1,003.25
IleTOT.'LLPFRl%*ff'tt,-CESDUFNC)'tV
�c
RECEIPT ATE
BY f
DATE FINALED
INSPECTOR
1F;k
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS v
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final 4POOLS
BLOCKWALL APPROVALS
- SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain.
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
.07/21/19,8. 18:23 9097597-8993 INFOTOX,INC. PAGE 02
'Anc.
As "monta, Spsei8fttiose, Air Monitoring,
A California Carporanon Anf tax, Sampling, Analysis, AHERA Training
July 21,199$
Mr. William Tribble
Tribble Construction
80-655 Ave. 43
Indio, CA 92201
Phone: (760) 347975.5
Fax: (760) 342-9825
Subject: Residential Structure Asbestos Survey
46-775 Washington, Indian Wells, CA .
Infotox, Inc. Project # 982057
Dear Mr. Tribble:
On July 17, 1998 Infotox, Inc. performed an asbestos survey of the residential structure
located at 46-775 Washington, Indian Wells, CA. Non destructive representative
sampling techniques were employed.
Only those materials noted as being scheduled to be part of the renovation process were
sampled and analyzed. Materials that were not sampled which are suspect asbestos -
containing materials are the exterior stucco, rear roof material, and entry closet acoustic •
ceiling. If these materials are later scheduled for removal; they should be sarnpled and
analyzed prior to disturbance.
The collected samples were delivered to an independent NVLAP. approved laboratory for
analysis by Polarized Light Microscopy (PLM). The method of analysis used has a limit
of detection of 1%. CAL/OSHA defines an asbestos containing material (ACM) as a
material containing greetter than 1/10 of 1% asbestos. Other government agencies define
an ACM as a material containing greater than 1% asbestos. Samples analyzed initially as
<1 % asbestos can undergo additional analysis by PLM point counting to determine
asbestos content to a detection limit of 1/10 of IYo for CAL/OSHA regulatory purposes.
Attached to this letter is a prepared inspection report that identifies in detail each of the
sampled suspect materials -and the results of independent laboratory analysis.
Asbestos containing materials are not considered a health hazard until and unless asbestos
fibers are released into the atmosphere.
t
9131 Oreo Parkway, Suite J, RiversMe, Calitorn.1a 92SO94M • (M 6 &SM / Am t96'1) GIS -4M
Realma+ed Camfournh Arbestoa Cas b
'' 47/21/198 18:23 909-59778993 INFOTOX,INC. PAGE 03
A fiber release may occur from many causes. Common causes of fiber release include
mechanical force, delamination after water damage, air •movememt over damaged
materials, etc:
Infotox, Inc. recommends that disturbance of asbestos -containing materials be avoided to
prevent exposure to airborne asbestos fibers.
EPA (NESHAP) and South. Coast Air Quality Management District (SCAQMD)
regulations require that asbestos-r-onudning materials be removed from a structure prior
to demolition or renovation activities that may disturb the materials.
We recommend that any work involving asbestos-cuataining materials, be performed by a
California Licensed and Registered Asbestos Abatement Contractor.
If you should have any questions regarding this report, please call our office at your
convenience.
Thank You for the opportunity to provide you with these asbestos management services.
Sincerely.
Infotox, Inc. by
Michael A. Nieuw_landt
President
Certified Asbestos Consultant
No. 92-0271 r
the - 2
07/21/1998
18:23 909-597-8993
INFOTOX,INC.
PAGE 04
Pape 1
Smote Su mry Report 48y Project)
Project Id: 982057
Report pate: 07/21/48
PRI SAMPLE.,
TYPE OF MATERIAL TVP
% COND ACCESS
DIST
COMMENTS
Area ID: 46-775
WASHINGTON plan/sheet ref N/A /B 1
4 46775-01
C
-1.00 FAIR EASY
LOW
COLLECTED FROM FRONT HALL CLOSET. MINOR
DRYWALL AND JOINT COMPOUND
DRYWALL DELIS REMAINS. GARAGE WALLS APPEAR
TYPICAL. SEE SAMPLE # 02.
4 46775-02
C
-1.00 FAIR EASY
LOM
COLLECTED FROM GARAGE REAR WALL. APPEARS TYP-
ORYWALL AND JOINT COMPOUND
[CAL OF INTERIOR CLOSET, ASBFSI'os DETECTED IN
JOINT COMPOUND.
0 46775-03
'MRD
0.00 POOR EAST
MOD
COLLECTED FROM FIRE DAMAGED AREA. KOTED AS
DRYWALL
REMNANTS 'ON WALL STUDS.
0 -46775-04
NO,
0.00 POOR EASY
HIGH
COLLECTED FROM ATTIC SPACE AT FRONT ENTRY.
ATTIC INSULATION
NOTED AS DEBRIS IN REMAINING ATTIC AREAS AND
ON FLOORS. LOOSE FILL TYPE INSULATION.
0 46775-05
NO
0.00 GOOD SPECIAL
LOW
COLLECTED FROM MAIN ROOF. WHITE COMPOSITION
ROOF'MATERIAL
SHINGLE OVER -06 ROOF FELT.
0 46775-06
NO
0.00 GOOD SPECIAL
LOW
COLLECTED FROM MAIN ROOF, LANDER WHITE COMPOS -
ROOFING FELT
ITION SHINGLE. OVER PLYWOOD, `
0 NOTE -01
0.00 FAIR EASY
MOD
PHOTOGRAPH OF RESIDENTIAL STRUCTURE AT 46-775
PHOTOGRAPH ONLY
WASHINGTON. INDIAN WELLS. PARTIALLY FIRE
DAMAGED INTERIOR.
0 NOTE -OZ
NO
0.00 FAIR EASY
MOD
WILL AND DUCT INSULATION NOTED AS FIBERGLASS.
INSULATION
NOT A SUSPECT ASBESTOS CONTAINING MATERIAL
(ACM).
0 NOTE -03
0.00 FAIR SPECIAL
LOW
THE REAR FLAT ROOF WAS NOT SAMPLED AND WAS
ROOF MATERIAL
NOTED AS NOT SCHEDULED FOR RENOVATION. ROOF
MATERIALS ARE SUSPECT ACM.
0 NOTE -04
0.00 FAIR EASY
LOW-
THE EXTERIOR STUCCO MATERIAL WAS NOT SAMPLED.
ROOF MATERIAL
STUCCO MATERIALS ARE SUSPECT ACM.
7 NOTE -05
C
-,5.00 GOOD SPECIAL
LOW
ONE EACH ASBESTOS CEMENT VENT PIPE WAS NOTED
'
ASBESTOS CE14ENT VENT PIPE
THROUGH THE ROOF ABOVE'THE WATER HEATER.
THIS MATERIAL IS ASSUMED TO BE ASBESTOS
CONTAINING.
A9b*stos 'TYP'
coda legend: 'C' - chrysotite
-A- - affmito '
'CR' - crocidolite
'TR' - tremtite
'AM' - 'enth%hyllite
'AC' - actinotite
"ND' - not datectad .
Trace and aasrts Less than 1% are reported as -17t
• ;07/21/1;998" 18:23 909-597-8993
INFOTOX,INC.,
PAGE 05
Page 2 Semple SLm nary Report (By Project)
Project Id: 982057
Report Date: 07/21/98
PRI SAMPLE TYPE OF MATERIAL TYP
% COND ACCESS DIST
COMMENTS
^ --^
0 NOTE -06
- ---- ------ ' ----
0.00 GOOD OVERHEAD LOW
--------
THE FRONT ENTRY CLOSET CEILING HAS A SPRAY
ACOUSTIC CEILING SPRAY
APPLIED ACOUSTIC CEILING MATERIAL WHICH IS
A SI1SPF" ASRFSTns r.ONTAININC MATERIAL. THIS
MATERIAL NOTED AS NOT SCMED, FOR RENOVATION,
Number of Samples Reported in this 2 page report is
------ 12 .
Asbestos 'TYP' Code legend:. 'C' - chrysotile
'A' - amosite
'CR' - crocidolite
'TR' - tremolite
'AN' - anthophyLLite
'AC' - actinoLit®
'ND' - not detected
Trace and amounts Less than 1% are reported as -1%
r
4
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