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0303-144 (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 Signature of Contractor OWNER -BUILDER DECLARATION 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, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ( ) 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. (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: Applicant Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to. any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. Signature (Owner/Agent) Date BUILDING PERMIT PERMIT••{`--#`�,�'yy�gy, 1 �yy ' R3aTCAw%'-' 4, 1,, DATE VALUATION LOTS TRACT JOB SITE APN ADDRESS tO 801 A 1'sM fiy4 OWNER CONTRACTORr / DESIGNER/ EN &NEEpR7 ( g p y t y [ +t Y :�Z�y^^"S�qq,J�.���y,.�7yy�tl:A'�`�qy�r~.yy�'1�t.8't y l���,'�}:1. {{'7�qq �pD, y,��y j�1 ,p 9-295 d�+i'4f"VCd3O �. y���.4�M�,t.aP°A )—,s ' A'A,, �.�,l,}}k"pq�d.''y�,�,'3gM,d�q.}p/ qq�'1lSi:i!•'i��.J 82 - ,J 4 Q S%4.it�:{.'Ca.6'Y.LAN �rz41t,., cau# 2809 USE OF PERMIT .y. �.xp��,l�$��p�,II j��pE�8i`.� �gy�� yq p.p y �p ty yy}+ y y k ��{ f l.a.EMO TO A A Rt biY{OLT14D \.Aif' 51145. 14, V AM X, E A.&OWDi$'NEMNT.L".$,9.$`." APPkk(A1A.:. PFR- F116,11MAJI-IT) MIST OW (XANSTRAM71,K)IN 3. W.i+ 0,1 ,l S CON f i" 01 10 S - 000 -4 2iJ"W0 g T6}t r�i`� `+� `�t.�%l �yy$l33:� �.•tCC`yy�$ 55!t$ yy �^ypp yYyy ** 6 YdE .'.'�',4: Rh.SRtt,.1 9! •,q',pla.Q E:S'�, ,%Fl �i't T(�lo", s43t.� 1AA'R 1 2D Q4Wa iA i OV LA R FIttiANta s SST . u RECEIPT DATE BY DATE FINALED INSPECTOR INSPECTION wag BUILDING APPROVALS OPERATION ' rjINSPECTOR MECHANICAL APPROVALS Set Sacks unaergrouna uucts Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans OX to Wrap F.A.0 [ Insulation- - Firaplace P.L. Fireplace T.O. _ Party Wall insulation Pam Wall Firewall Exterior hath r,[l - int. l_�tn_— €,orad Beam . _ K!..L APPROVALS PLUMBINGAPPROVALS Shower Pans Sewer ? atai: i _ Seer Ccsnr�tior; Gas Fest ._,. Utility i r,': ce tGas) l ELECTRICAL Temp. Powrer Pale Underground Conduit ifough Wising _ rape Wiring main E to for i-e—c-e itac' &&s Smoke ',Detectors `ennp. Js,-- of : ower i 11tR!;ty �IOt1�e (Perrr�) .� Im ;steel Electric Bond Main Orain Approval to Cover Eauicment vacation Im Gas Piping Lias Tea" Fiec;tric Finai Healer Final II Tiurrbi o Fina[ O.K. for Finish Plaster r`€over Final �p i� L POO- SPAS SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT NOTIFICATION OF DEMOLITION OR ASBESTOS REMOVAL MAIL FM AND FEE TO SCAQMD, ASBESTOJ ADM Ulm twl v I . FILE f W"ll, LOS ANGELES CA 40074.3641 _-- --- -.�. -WWXA si RECI6m p0$7m 6 ENTERED BY NOTF"TI®bl IR C0IRPLETED 8Y1?aG 6 Y YG c4A COMPANY/ G r r PHONE 6 a-3 eth� y S Lams/( /e& 3 9 fs- a 5 DATE 27-�1- -1 CHECK # -3 1� - FEE $ �<— ?a PROJECT # NOTWCATiIOM TYPE REvmcN DATES ftASM OTHER (h~l) CANCELLATION PNOJ .C'T TM DEMOLFTiOF! OWERED DEMOLITiON REwvATKiN (wwyai) EMERGENCY REMOVAL PLMWD RENO (Nn*) WE NFOIIMATION SITE NAME G a r � � U' of � A! SITE ADDRESS 5o k 7`;� 44,1� 5 0 r r, e �-- 9L CROSS STREET .51 /, ,[ CITY Let 0 K" z i q STATE /f% ZJp COUNTY DESCRIBE WORK AND LOCATION /41 k4LDWG, SIZE (SQ FT) -3!5 G a NUMBER OF FLOORS BUILDING AGE (YEARS) 5 NUMBER OF DWELLING UNITS BLDG PR= I PRESENT USE c.OMmlt�4' L MOSMAL INDUSTRK OtPW OFM PVkX 1LDG.OUSE SCHOOL $HIP UW 440um a SITE OWNER T, V4), A S e tt P-0 !/-e /010?71.e l ADDRESS 4r O • 7/4 CITY,4q STATE C A, ZIP 'ij. ;L 5.3 CONTACT Gg r.' S /-"; PHONE REf;9RJM BU LDNiNG WFORMATION ASBESTOS YES NO PRESENT? ASBESTOS ES NO SURVEY? ASBESTOS � NO REMOVED? BUILDING TO BE NO �✓ DEMOLISHED? PIKIECT DIATU START .- 1 -� G �j END '� O S - c WORK SHIFT (day, swing, rtighq ? — ,S' IAMOUNT TO SE AENKMM (in square asst) FRIABLE CLASS I CLASS II TOTAL AMOUNT (add row) AnDITOff REMOVAL FROM SURFACES PIPES COMPONENTS AMOUNT OF EACH TYPE OF ASWJMX (in square lest) ACOUSTIC CEILING LINOLEUM INSULATION I FIRE PROOFING DUCTING STUCCO MASTIC FLOOR TILES (VAT) DRY WALLPLJISTEft TRANS ITE ROOFING OTHER (ft) CONTRACTOR NIFORMATM CSW LICENSE 0 3 fv G OSHA REG # AQMD ID # NAME Yo li fL q,? elC 1e q r,` ADDRESS S - S-.> -°! i 13 e c /T -h, CITY STATE SITE SUPVR� k y/ V PHONE G �'it�/�nai Cit ZIP'l�,a.7y rrr L ��n 3FSr-a S%S WASTE TRANW ORTER 611 LANDFILL To y �' � k - ADDRESS ADDRESS l)°e / 9 S CITY STATE ZIP CITY t%'�j, cf fr S 1 STATE C eE% Z1P 9.2.2 7Y Asbestos surveys are required print° to Demolition and Renovation Fomts, instr+ bons, and the Rule 1403 can be obtained from A®MD web site httplhyww.agmd.gov Page l of 2 Form REV 2002M7 SCAQMD NOTIFICATION OF DEMOLITION OR ASBESTOS REMOVAL MAIL ONUM TO SCAQMD, AUESTOS NOTIFICATIONS, FILE #UPI, LOS AUBELES CA 900743641 WASTE TRANSPORTER 82 WASTE STORAGE SPIE ADDRESS ADDRESS CITY STATE DP CITY STATE ZIP CONTROLS: DESCRIBE WORK PRACTICES AND CONTROLS TO BE USED AT THE RENOVATION AND DEMOLITION SITE. PmoaAws 01, 2.3.4. 5 or Oew. For s abeeioe removals c h de the wmbinebw d Rule 1403 procedures used. Pmowwre 4 and 5 wAmk plana for AQMD prior approval. ASBESTOS DETECTION PROCEDURE: CIRCLE THE PROCEDURES AND ANALYTICAL METHODS USED TO DETERORINE ASBESTOS IN THE BUILDING. Bulk Sars>piing, Irwpsedm, Survey, PLM, PCM, TEM, Assumed as Asrbestoe, Describe Otw. FOR DEMOLITIONS GIVE THE COMPANY NAME AND DATES OF THE ASBESTOS REMOVAL: 3 FOR 0 W E 1" DEMOLITION SEND A COPY OF THE ORDER AND GIVE THE AGENCY NAME Ili PHONE # AUTHORIZING PERSON: TITLE DATE OF ORDER: DATE ORDERED TO BEGIN: FOR EMERZKY ASIMWOS REMOVAL Gm TME NAME AND PHONE NiAm OF THE PERSON DEM ANWAftHORONG THE EMERGENCY, DATE AND MOUR OF EMFJNOW AND DESCIVIN THE SUDDEN, UP PED EVENT: EKPLAM HOIN THE E'WW 1l MA.D CAUSE UNSAFE OONDRIONS. SOL94AENT OAMAGE OR UNREASONABLE FINANCIAL BURDEN: CONTMIGENCY PLAN, I* ACT04 AND PROCEDURES TO SE FOU WED IF UtE�E� As1BESTOS 16 POLING D ~ DEMOLITION pR � MATERIAL BECOME PLILVER@YED, OR REDUCED TO POWO� r•�' t �' r e7 ccS 4� 1C" f7s /3pl�t.�� eCn7'f'4'G%�c,r� TRAI1/0 CERTIFTCATI011: I Certlfy thtt an kidM wl tmined In the provWm d raguiafion AQMD Rule 1403 and NESHAP wit bean slit during the ren oval and widaioe !fat ft reW ed baMV has been aocompkshed by this person W&I be waffle for k apection during ran, t buskmhours. Oomparty Name Print . mt of owwkparalor Sgnftre d omrrakpermw Tkk d mwrkpaalor Dat SPFOIIMATION CERTIFICATION: t oer6ly 61st Yte above Irlforrratlon r: oarrect and I have arrcbeed any required aftacd>nsorrfs. S �Re��✓ t lay+°^f+ /2ssc l6% �dc�Af C�Gvid/�r 2^) f -u �j you»OwnpiltNow Print rams d ownerkpereior Time of ownadopargor Dar NWIca ora are not accepted without the requintd asbestos fes (AQMD Rule 301). Renwvals d Was than 100 aqua* fest ars exempt from rsaWica&m and fees. Pfeeee maks deft payable to SCAQMD', Fees aro per wifficelim, not mfurrdabie, and vary awwft to"awedw amount 10 be ce nwm. Feee are ae tows : COMMERCIAL DEMROLITIONRiENOVATION RESIDENTIAL REMOVALS S 26.20 FROM 100 TO 1,000 SQUARE FEET $2620 REVISION OF NOTIFICATION $ 10.60 FROM 1,001 TO 5,000 SQUARE FEET $80.10 CANCELLATION OF NOTIFICATION $ 0.0 FROM 5,001 TO 10,000 SQUARE FEET 5187.10 PROCEDURE 4 OR 5 PLANS S 294.00 MORE THAN 10,000 SQUARE FEET $294.00 RETURNED CHECK CHARGE $ 28.00 DEMOLITION OF LESS THAN 100 SQ FT ;7620 SPECIAL HANDLING FEE $ 25.00 ATTENTION: Kruep a sow of Ymw ter a icaSori. Sate law MOW 1* frau provide a copy d Ree denwildon ndkotion b Bufding and 5a(ety bafoce iaallarloe d a awrrotNon perrilt. Far q>rubm call Ii0"W2336. For your www�iwm pleeee MIA tM Pam and fee and do not hand My b AQMD. MAIL FORM AND FEE TO: SCAtiYQ ASBESTOS NOTrMTOW FELE / 55/41, LOS ANOELES CA 600746641 TELEPHONE! (100) !66.2336 FAX: (NO) 30"M Alba" OerrsoiitiaNRanovation NO NCOWn Fam REV 990601 Page 2 d 2 Fmw Vubudons, sed to Rule UM an be abubw ftm AOAO web aL http Jt wvw.&gmd.QOv ENVIRONMENTAL [11,6144-A CERTIFICATE OF COMPLETION THIS IS TO CERTIFY THAT AN ASBESTOS ABATEMENT PROJECT HAS BEEN COMPLETED IN ACCORDANCE TO STATE & FEDERAL REGULATIONS AT Single Family Residence South 'West corner of Madison Avenue & Avenue 58 La Quinta, CA 92253 EKU JOB # 203-030 Abatement and disposal of non -friable roof mastic penetrations In accordance with Enviro-test survey 990304 dated Februwy 8, 2003. DATE February 20, 2003 JOB NAME Young's Land Clearing Rocky Young PROJECT COMPLETYO ITNESSED BY Beverlgy Ann P.O. Box 285 Mira. Loma, C;,A,. W52 Phone (:909) 685-531.4 Fax (909) 681-5559 License 4684979 UOSH#595 7.0 39Vcl n>13 6999139606 01:bT Eoaz/©T/co �Q�e����� C�=������e Post Office Box 1716 La Quinta, California 92253 Telephone: (760) 771-1941 Fax: (760) 771-1841