BDEM2019-000778-495 CALLE TAMPICO Tih/ D 04 Qa4a
LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT
BUILDING PERMIT
Permit Type/Subtype: DEMOLITION/COMMERCIAL/OTHER
Application Number:
BDEM2019-0007
Property Address:
78480 HIGHWAY 111
APN:
604050042
Application Description:
OKURA / INTERIOR DEMOLITION ONLY [NO OCCUPANCY]
Property Zoning:
Application Valuation:
$20,000.00
Applicant:
RUBEN CORONADO - STATEWIDE SERVICES INC DBA. TA E [Dt_ N `--` j
73-700 DINAH SHORE DR #405
PALM DESERT, CA 92211 APR 0 3 2099
CITY OF L-, QUINTA
DESIGN & DEVELOPMENT DEPARTMENT
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter
9 {commencing with Section 70001 of Division 3 of the Business and Professions Code,
and my License is in full force and effect.
License Class: B License No.: 951607 L
Date: 2 O/ Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State
License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair
any structure, prior to its issuance, also requires the applicant for the permit to file a
signed statement that he or she is licensed pursuant to the provisions of the
Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division
3 of the Business and Professions Code) or that he or she is exempt therefrom and the
basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a
permit subjects the applicant to a civil penalty of not more than five hundred dollars
($500).:
(_) 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 and Professions Code: The Contractors' State License Law does not.
apply to an owner of property who builds or improves thereon, and who does the work
himself or herself through his or her own employees, provided that the improvements
are not intended or offered for sale. If, however, the building or improvement is sold
within one year of completion, the owner -builder will have the burden of proving that
he or she did not build or improve for the purpose of sale.).
(_) 1, as owner of the property, am exclusively contracting with licensed contractors
to construct the project. (Sec. 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or improves
thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law.).
(_) I am exempt under Sec. . B.&P.C. for this reason
Date
Owner:
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's
Lender's
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 4/3/2019
Owner:
SSH GROUP, LLC
78480 HWY 111
LA QUINTA, CA 92253
Contractor:
STATEWIDE SERVICES INC DBA STATEWIDE CON
73-700 DINAH SHORE DR #405
PALM DESERT, CA 92211
(760)699-5434
Llc. No.: 951607
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 and policy number are:
Carrier: BENCHMARK INSURANCE COMPLNY Policy Number: CST5015156
I certify that in the performance of the work for which this permit is issuer!, 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' •compensat ion provisions of Section 3700 of the Labor Code, I shall forthwith
comply with those provisions.
Date:y�Z 0/1 --Applicant:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($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.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
the conditions and restrictions set forth on this 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 application , the owner, and the applicant, each agrees to, and
shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and
employees for any act or omission related to the work being performed under or
Following issuance of this permit.
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.
certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
-onstruction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. , L
)ate: V 2d*Signature (Applicant or Agent):
Application Number:
BDEM2019-0007
Property Address:
78480 HIGHWAY 111
APN:
604050042
Application Description:
OKURA / INTERIOR DEMOLITION ONLY [NO OCCUPANCY]
Property Zoning:
Application Valuation:
$20,000.00
Applicant:
RUBEN CORONADO - STATEWIDE SERVICES INC DBA STATEWIDE CON
73-700 DINAH SHORE DR
#405
PALM DESERT, CA 92211
Date: 4/3/2019
Owner:
SSH GROUP, LLC
78480 HWY 111
LA QUINTA, CA 92253
Contractor:
STATEWIDE SERVICES INC DBA STATEWIDE CON
73-700 DINAH SHORE DR #405
PALM DESERT, CA 92211
(760)699-5434
Llc. No.: 951607
Detail: INTERIOR DEMOLITION OF EXISTING RESTARUANT FEATURES AND IMPROVEMENTS. THIS PERMIT DOES NOT INCLUDE OCCUPANCY OR
CONSTRUCTION, OR ALTERATION TO EXISTING LOAD BEARING OR LATERAL RESISTING CONSTRUCTION. 2016 CALIFORNIA BUILDING CODES.
FINANCIAL INFORMATION
DESCRIPTION ACCOUNT
QTY
AMOUNT
DEMOLITION, INTERIOR
101-0000-42404
0
$40.02
DESCRIPTION
ACCOUNT
QTY
AMOUNT
DEMOLITION, INTERIOR PC
101-0000-42600
0
$107.27
Total Paid for DEMOLITION: $147.29
DESCRIPTION ACCOUNT
QTY
AMOUNT
RECORDS MANAGEMENT FEE 101-0000-42416
0
$10.00
Total Paid for RECORDS MANAGEMENT FEE: $10.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
TECHNOLOGY ENHANCEMENT FEE
502-0000-43611
0
$5.00
Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00
r
SERVICES INC.
Ucense #I 951607 ■ GENERAL CONTRACTOR • ARCHITECTURAL DESIGN ■ CONSTRUCTION MANAGEMENT
License 4 936147 • GENERAL ENGINEERING
April 3, 2019
To Whom It May Concern:
This letter serves to authorize Travis Lumsden, Account Assistant for Statewide Services, Inc to
pull permits, permissions, and submit plans on behalf of the company with the city of La Quinta.
If you need further confirmation, please contact me.
Sincerely,
0�
Ramon A. Fimbres
CEO/President
Statewide Services, Inc
Office 760.699.5434
Cell 760.393.6115
PLEASE SEE ATTACHED NOTARY ACKNOWLEDGEMENT
Statewide Services, Inc
7370o Dinah Shore Drive, Suite 405 • Palm Desert, CA 92211
76o.699.5434 Office • 76o.699.5466 Fax •
www.statewideinc.net
ra
ta
— CAt WORNiA
SDEM70
PERMIT # 1 MP 000
PLAN LOCATION:
Project Address: '-Igo Loy t
Project Description:
APN #: - OSCE - O 1i Z
�Yt
f13'a
Patio/Porch SF
F
Applicant Name: ,�
Address: 'T 3 7
State Lic: City Bus Lic:
City, ST, Zip: ' n Ir c t (,' �Zl
Telephone: 7 0
Email:
Valuation of Project $ :2 of Occ e7
Contractor Name: Sf
New SFD Construction:
Address: -��-�
Conditioned Space SF
City, St, Zip
Garage SF
Telephone: C _
Patio/Porch SF
Email: �*KC ne t-
Fire Sprinklers SF
State Lic: (7S 1&01 City Bus Lic:
Architect/ Engineer Name: .
Construction Occupancy:
Address: `'
Grading:
City, St, Zip
Construction Type: Occupancy:
Telephone:
Bedrooms:
Stories:
# Units:
Email:
State Lic: City Bus Lic:
Property Owner's Name:I
1_ _Ie,
1 New Commercial / Want Improvements:
Address:
Total Building Da SF
City, ST, Zip
Construction Type: Occupancy:
Telephone:
-Email:
E m a i 1:
78495 CALLE TAMPICO
LA QUINTA, CA 92253
760-777-7000
,•1-5
SSR Group, LLC
ACKNOWLEDGMENT OF INTERIOR DEMOLITION
3/19/19
To Whom It May Concern,
Please accept this letter as acknowledgement and approval for Statewide Services, Inc. to perform interior
demolition work, per submitted plans at 78480 Hwy 111 La Quinta, CA 92553.
Should you have any questions, please feel free to contact me.
Sincerely,
Sookhee Lee Sin
Authorized Signer
RECEIVED
LIAR 2 0 2019
CITY OF LA QUINTA
COMMUNITY DEVELOPMENT
I ST
DIGITAL MOLD ANALYSIS
CORPORATE OFFICE
31855 Date Palm Dr. Suite 3-444
Cathedral City, CA 92234
California Toll Free 866 -MOLD -ABC
(LA) 310.545.8770 (CC) 760.776.4030 (FAX) 760.766.3358
Digital Mold Analysis inspected property located at 78480 Highway 111, La Quinta, Ca
Inspection requested by: Statewide Construction
Date: 3-07-19 Time: 3:00pm Inspected by: R. Hechtman
Asbestos was NOT present in one or more samples
Results and Recommendations:
The following tests were performed in compliance with accepted EPA General Testing
Standards for Asbestos:
(a) Test ID # 031119-0151 (Wall Mud at Men's Rm) BULK Asbestos Resulted ( 0%)
(b) Test ID # 031119-0152 (Wall Mud at Wom's Rm) BULK Asbestos Resulted ( 0%)
(c) Test ID # 031119-0153 (Wall Mud at Kitchen)
COVER PAGE
BULK Asbestos Resulted ( 0%)
RECEIVED
MAR 2 0 2019
CITY OF LA QUINTA
COMMUNITY DEVELOPMENT
1W
DIGITAL MOLD ANALYSIS
1675 North Commerce Parkway, Weston, FL 33326 (954) 384-4446
31855 DATE PALM DR SUITE 3-444
CATHEDRAL CITY, CA 92234
CERTIFICATE OF BULK ASBESTOS ANALYSIS
Prepared for:
DIGITAL MOLD ANALYSIS
Phone Number:
Fax Number:
Email Address:
bgbet@aol.com
Project Name:
STATEWIDE
Test Location:
78480 HWY 111
LA QUI NTA, CA 92253
Chain of Custody #:
1216980
Date Sampled:
March 7, 2019
Date Reported:
March 11, 2019
Andrew Pittman, Analyst
It is certified by the signatures above that PRO-LAB/SSPTM, Inc. is accredited by the National Institute
of Standards and Technology for Polarized Light Microscopy (PLM) analysis under the EPA 600/M4-82-
020 Method. All analyses are performed using the EPA 600/R-93/116 method. The refractive index was
determined by using 'Rapidly and Accurately Determining Refractive Indices of Asbestos Fibers by using
Dispersion Staining Method', by S -C. Su. This report must not be reproduced in full, without written
approval from PRO-LAS/SSPTM, Inc. These test results apply only to the samples ar.lvarty tesred.
Polarized light microscopy is not always an accurate way to analyze Floor tiles. When a r;on-de;ecl or
very low percentage of asbestos occurs, a transmission elir,;ron microscopy analysis (TEM) may be
warranted. All samples will be stored for a period of three months. The information contained in this
report and any attachments is confrdenliai information intended only for the use of the individual or
entities nan)W above. Limit of Deleclion (LOD) = 1%,
For more information please contact PRO -LAB at (954) 384-4446 or email infarfprolabinc.com
Page 1 of 2
pRQ"L/Q 1675 North Commerce Parkway, Weston, Ill. 33326 (954) 364-4446
STATEWIDE
78480 HWY 111
LA QUINTA, CA 92253
March 7, 2019 Samples
CH=Chrysotile AM=Amosite
CR=Crocidolite AN=Anthophylite
TR=Tremolite AC=Actinolite
ND=None detected
Page 2 of 2
Asbestos Mineral Percentage
Client ID
PRO -LAB ID
LOCATION
COMMENTS
CH
AM
CR
AN
TR
AC
ND
A
031119-0151
CREAM/RED
3% Cellulose
WALL MUD AT MENS ROOM
0
0
0
0
0
0
NO
2% Mica
95% Binders
B
WHITE
75% Cellulose
031119-0152
WALL MUD AT WOMEN'S ROOM
0
0
0
0
0
0
NO
3% Mica
22% Binders
CREAM/RED
3% Cellulose
C
031119-0153
WALL MUD AT KITCHEN
0
0
0
0
0
0
NO
2% Mica
95% Binders
CH=Chrysotile AM=Amosite
CR=Crocidolite AN=Anthophylite
TR=Tremolite AC=Actinolite
ND=None detected
Page 2 of 2