331 E. Simmons Ave.
&
SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT
NOTIFICATION OF DEMOLITION OR ASBESTOS REMOVAL
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MAIL FORM AND FEE TO SCAQMD, ASBESTOS NOTIFICATIONS, FILE # 55641, LOS ANGELES CA 9!lm....
DATE I. ftJ.tJr CHECK#
FEE$
PROJECT#
NOTIFICATION TYPE
ORIGINAL
REVISION DATES
REVISION OTHER (highlight)
CANCELLATION
PROJECT TYPE
DEMOUTI
OROEREO DEMOUTION
RENOVATION (remova~
EMERGENCY REMOYAL PLANNED RENO (annual)
SITE INFORMATION SITE NAME ~ /l; gl€- .!.,8 r:-
SITE ADDRESS . j;31 tF !?;NJNJtJlI!$ A~ CROSS STREET
CITY /tNtt~ SIATE ~ _ZIPfJP~__CQlJ~
DESCRIBE WORK AND LOCATION
BUILDING SIZE (SQ FT)
BLOG PRIOR I PRESENT USE
NUMBER OF FLooijS hI(
BUILDING AGE (YEARS~ NUMBER OF DWELLING UNITS
HOSPITAL INDUSTRIAL O1her OFFICE PUBUC BlDG. HOUSE
ScHOOL SHIP UNIViCO!.LEGE
SITE OWNER
REQUIRED BUILDING
INFORMATION
ASBESTOS
PRESENT?
NO
PROJECT DATES
START J7 -,$. <1- ~ t).r
END t? ~b - tJ S- WORK SHIFT (day, swing, night)
'ASBESTOS AMOUNT TO BE
REMOVED (in square feet)
FRIABLE
CLASS I
CLASS II
TOTAL AMOUNT (add row)
'ASBESTOS REMOVAL FROM
SURFACES
PIPES
COMPONENTS
'AMOUNT OF EACH TYPE OF
ASBESTOS (in squBre feet)
ACOUSTIC CEILING LINOLEUM INSULATION FIRE PROOFING DUCTING
STUCCO MASTIC
OTHER (descnbe)
OSHA REG #
AQMD 10 #
NAME
WASTE TRANSPORTER #1
LANDFILL
~
Pili
PHONE
CITY
ADDRESS
ADDRESS
CITY
STATE
ZIP
CITY
STATE
ZIP
, Not required for demolition notifications 1 asbestos surveys are required prior to Demolition and Renovation.
Forms, instructions, and the Rule 1403 can be obtained from AQMD web site http:/twww.aqmd.goY Page 1 of 2
SCAQMD NOTIFICATION OF DEMOLITION OR ASBESTOS REMOVAL
MAIL FORM AND FEE TO SCAQMD, ASBESTOS NOTIFICATIONS, FILE # 55641, LOS ANGELES CA 90074-5641
WASTE TRANSPORTER #2 . 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.
For asbestos removals circle the combination of Rule 1403 procedures used. Procedure 4 and 5 submit plans tor ACMD prior approval (See procedure 4/5 guidelines)
, '
. ASBESTOS DETECTION PROCEDURE: Circle the'procedures and analytical methods used to determine the presence of asbestos in the building. Survey, Bulk
Sampling, Inspection, PLM. PCM, TEM. Assumed as Asbestos.PACM. Describe Other (See survey guidelines checklist): .
FOR DEMOLITIONS GIVETHE COMPANY NAME AND DATES OF THE ASBESTOS REMOVAL: NlI'I-
FOR ORDERED DEMOLITION SEND A COPY OF THE ORDER AND GIVE THE AGENCY NAME & PHONE #
AUTHORIZING PERSON: TITLE ,
DATE OF ORDER: I 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 (Oislullled /damsged .sbestDS requires. procedute 5 plan .pproval prior 10 c/ealHJp):
EXPLAIN HOW THE EVENT WOUUD CAUSE UNSAFE CONDITIONS, EQUIPMENT DAMAGE OR UN~EASONABlE FINANCIAL BURDEN:
CONTINGENCY PLAN: DESCRIBE ACTIONS TO BE FOLLOWED IF UNEXPECTED ASBESTOS IS FOUND DURING DEMOLITION OR ASBESTOS MATERIAL BECOME
DISTURBED. CRUMBLED, PULVERIZED. OR REDUCED TO POWDE~~1u1lled /danraged .sbeSIoS requires. zrUte 5 plan spproval PriO';..1o cietnolJp):
, /F:? 0M- ,,1det>~ ~ r- a. Uf-6e 4t1e-o '~- t(!
. TRAINING CERTIFICATION: I certify that an individual trained in the provisions of regulation AOMD 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 nonmal business hours. '
Company Name Print ~me of owner/operator Signature of owner/operator Tittle of owner/operator Date
INFORMATION CERTlRCATlON: I certify that the above ihfonmation is correct and I have enc~ts. qP. /tl. tJ..r-
()/VIM- m~" e. l7t/fAl'// ~ .
Company Name Print name of owner/opera r Signature of owner/ rfP"" Totti. of owner/operator Date
Notifications can not be accepted without the required fee (Rule 3011. Aabestos removals of less than 100 square feet are exempt from notification and fees.
Please make checks payable to 'SCAOMD'. Fees are per notifi~ not refundable. and vary according to the project size. Fees are as follows:
PROJECT SIZE in square feet DEMOLIT rncMOVAL ADDITIONAL SERVICE CHARGES
1,000 or less ........-............... $39.11 ~....................... Special Handling Fee .... $ 39.11
1,001 to 5,000 .......................... $ 119.57 ................-_........ Revision to Notification. . $ 39.11
5,001 to 10.000 ................-....- $ 279.87 ............................ Returned Check Fee ... . $ 31.97
1 0.001 to 50.000...--................ $ 438.85-....-..................... Planned Renovation .-. . $ 438.85
50.001 to 100,000 .......-......-.... $ 636.00 ............................ Procedure 4 or 5 Plan....-$ 438.85
100 DOlor more ....--......... ... $ 1 060.00 ....................-....
ATTENTION: Keep a copy of your notification, State law requires that you provide a copy of the demolition notification to Building and Safety before issuance of a
demolition permit. For questions call 909.396-2338. Piease mail the form and fee to AOMD. Mailing saves time. money and reduces traffic and air pollution
MAIL FORM AND FEE TO: SCAQMD, ASBESTOS NOTlRCATlONS, FILE # 55641, LOS ANGELES CA 90074-5641 Pg 2 of 2
FORMS,INSTRUCTIONS, AND THE RULE 1403 CAN BE OBTAINED FROM AOMD WEB SITE AT HTI'P://WWW.AOMD.GOV
SCAQMD is located at 21865 Copley Drive, Diamond Bar, CA 91765-4182 PHONE: (909) 396-2336 FAX: (909) 386-3342 REV20050615
APPLICANT: PHUC HUYNH
OWNER INFORMATION: CONTRACTOR INFORMATION: ARCHITECT/ENGINEER INFORMATION:
PHUC HUYNH
331 E SIMMONS AVE
ANAHEIM, CA 92802
JOB DESCRIPTION:Demolish 390 square foot (13 x 30) storage room.
VALUATION: 500.00 PROCESSED BY: MSM
I OWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason (Sec. 7031.5 Business and
Professions Code: any city or county which requires a permit to construct, alter, improve, demolish or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
9)(commencing with Section 7000 of Division 3 of the Business and Professions Code) or that he 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).
D I, as owner of 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 Contractor's License Law does not apply to an owner of property who builds or improves
thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or
offered for sale. If, however, the building or improvement is sold with one year of completion, the owner-builder will have the burden of proving that he
~. not build or improve for the purpose of sale).
I, as the owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044 Business and Professions
ode: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with
~ontractor(s) licensed pursuant to the Contractor's License Law).
U I exem under Sec. , B & .C. for this r 0:
Date: Owner:
WORKER'S C . MPE AT LARATION
I hereby affirm under penalty of perjury one of the ollowing declarations:
D I have and will maintain a certificate of consent to self-insure for worker's compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which
this permit is issued.
o I have and will maintain worker's compensation insurance, as required by Section 3700 of
the Labor Code, for the periormance of the work for which this permit is issued. Myworker's
Compensation insurance carrier and policy are:
Carrier: Policy Number.
BUILDING PERMIT NO. BLD2005-02476
TYPE OF PERMIT CITY
Demolition
DATE: 8/9/2005
JOB ADDRESS: 331 E SIMMONS AVE
LEGAL DESCRIPTION: ORANGEWOOD TR LOT 10 POR OF LOT
ih section need not be completed if the pennit is for one hundred dollars ($1 00) or less.
I certify that in the periormance of the work for whiCh this permit is issued, I shall not
ploy any person in any manner so as to become subject to the worker's compensation laws
of Califomia, and agree that if I should become subject to the worker's compensation
provisions of Section 3700 of the Labor Code, I shall forthwith comply with those R ons.
Date: 8/9/2005 Applicant:
WARNING: FAILURE TO SECU EWORKER'S
UNLAWFUL, AND SHALL SUBJECT AN E LOYER TO CRIMINAL PENALTIES AND CIVIL
FINES UPTO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDlllON TO THE
COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE
LABOR CODE, INTEREST AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the
periormance of the work for which this permit is issued (Sec.3097.Civ.C):
Lender's Information:
I certify that I have read this application and state that the above information is correct. I
agree to comply with all city ordinances -and state laws relating to building construction, and
hereby authorize representives of this city to enter upon the above mentioned property for
in ection u ooos.
Date: 8/9/2005
ignature
lhe per . expIre y limitation and become null and void if the building or
work has not passed final inspection 365 days from the date of permit issumce, A
new oarmit is reauired to commence or continue work.
ElM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
INSPECTION REQUEST LINE:
(714) 765 - 4626
CENSUS CODE: 649
QUARTER SECTION: 99
LICENSED CONTRACTORS DECLARATION
I hereby affirm under penalty of perjury that I am
licensed under provisions of chapter 9 (commencing
with Section 7000) of Divsion 3 of the Business and
Professions Code.
8/9/2005
Date:
Contractor
NUMBER
EXPIRATION DATE
TYPE
Construcion Types:
VN, ,
ire Sprinklered?
NO
Fees paid for Permit:
Total:
357.04
City of Anaheim
Building Division
INSPECTION RECORD
INSPECTION DATE INSPECTOR
Temporary Power Pole
Plumbing (DrainfWaste Pipe)
Electrical Ground Electrode/Ufer
Setback/FormslTrenches (Footings)
Do not install subfloor or pour floor slab until the
following applicable items have been signed:
Plumbing (Water Pipe/Sprinkler Valves)
Mechanical (Groundwork)
Electrical (Underground Conduit)
Pre-slab (Compaction/Membrane Reinf.)
Underpinning (Floor Joist/Girders)
Do not cover or conceal the work below unlilthe
following applicable items have been signed:
1 st Floor Shear
Firesprinkler (Rough)
2nd Floor Shear
Roof (Sheathing/Diaphragm/Frame)
Masonry (Reinf./Bond Beam/Pre-Grout)
Rough Plumbing (Top Out)
Rough Mechanical
Rough Electrical (Dry Wall)
Rough Electrical
Framing (Only after Plbg., Ele., Mec. And Fire)
Insulation (Sound/Energy)
Do not tape or plaster until the following applicable
items have been signed:
Drywall
Penetrations (Fire Rated) EleC1rical
Penetrations (Fire Rated) Mechanical
Penetrations (Fire Rated) Plumbing
Interior Lath
Exterior Lath
GENERAL ITEMS
Exterior Plaster (Brown Coat)
T-Bar Electrical
T-Bar Mechanical
T-Bar Structural
Sewer
Water Engineering Backflow
Water Service
FINAL INSPECTIONS DATE INSPECTOR
Electrical Final
Plumbing Final
Mechanical Final
Gas Test
Engineering/Grading Final 765-5126
Fire Dept. Final 765-4040
Water Engineering 765-5268
Sub List/Business License 765-5194
Zoning 765-5139
Building Final (Last Inspection - Only lP;e>-tl( ~~
After Above Complete)
PARTIAL INSPECTIONS
Building Inspections
Mechanical Inspections
Plumbing Inspections
Electrical Inspections
i
---
CITY OF ANAHEIM
OFFICE OF
Bunding Inspector
...
~y
...
...
Will a water closet be provided for each family?.
Give area of water closet apartment or room, when ftnished.___
Give size of windows for toilet and bathrooms
Specify size of vent shaft to water closet comDartment~
~5tD,C[) \)~
PPLlCA nON :FOR BUILDI N
wner
> /icant to' fill ,in area within h...
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lI,nes on Iy.
oIlln
/ty
fchltoct Gr.-.englne.r
rJdN1ss
Phone'
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ZOIUNG
PATE RECEIVED:
"ZONE
ACCE$$ORY USE:
APPLICATION
ECKED BY:
TE CLEARED:
IN USE:
REQUIREMENTS
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IItllnti ~etboclc Irom planneJ
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width depth,
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'(preis:
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,king spoces or . .
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r1dng: .
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rdOY
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ga,roge,.,requlreJ:
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:CLASS
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.ANTED NO
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EFFECTIVE
DATE:
EFFECTIvE
DATE,
EFFECTIVE
DATE:
Y.. 0 No 0
Y.. D No 0
Y.. 0 No D
, '
.flr/NG FEE PAiD7
,RKS FEE PAID7
;NS APPROVED?
:VJ,EW BOARD APPROVAL:
'HER CONDITIONS AND/t?R REMARKS:
CODE REQUIREMENTS. S"".",& So...o..
'PROACHES MEET SPECS.
~EWALKS:
Sewer Fe.
Due
,I~, =:> OJ " V-'ualr.erecelvea
'.' 'Date issued
CITY OF ~ HElM' Permit No.
NEW~O
S':t4
Sq. Fl.
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Fomlll.. '
Us. of
FIr.
, ZCUUI
qccuponc)'.. roup'
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T.ype of Co"."Ue~J_Dn:~,
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Fe.. S
TOTAL;2.l 5_
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Approvo
FO : CA
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GROUND.PL.UMBING
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LATH OR DRYWAL.l.
INTERIOR
LoATH EXTERIOR'
PL.ASTER.BROWN.COAT
FINISH PLUMBING
FINAL ELECTRIC
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HEAT FINAL
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LANDSCAPING
WALL.S
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