1001 W. Lincoln Ave.
CONTRACTOR INFORMATION:
lHREE 0 SERVICE CO
1515 EMISSION
POMONA, CA' 917660000
BUSINESS PHONE: 909469;'600
JOB DESCRIPTION: Demolish 2500 squ~re feet of structure on rear
VALUATION: 6,000.00
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, alte.r. improve, demolish or repair any structure, prior to its issuance, also
requ ires the applicqnt for such permit to file, a signed statement that he is Iice'r.,';sed .pursuant to the provisions of the Contractor's License Law (Chapter
9)(commencing with Section 7QOO of Division 3 of the Business and Prof~sslol~sCode) or that he is exempt the'refrom and the basis for the alleged .
exemption.. Any violation of Section 7031.5 by any applicant for a permit subject,,> the applicant to a civil penalty Of not more than five hundred dollars
($500). . . '.
o I, as owner of property, or my employees with wages as their sole compEl;'sation, Will do the work, and the structure is not intended or offered fo~
sale (Sec. 7044 Busif1ess a nd Professions Code: The Contractor's License ~z;w 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 ow0cmployees, provided that slIch improveinentsare npt intended or .
offered for sale. If, however, the bUilding or improvement is sold with one year of compleiion, the owner-builder will have the burden of proving that he
did not build or .improve for the-purpose of sale). i ." .
o I, as the owner of the property, am exdusivetY contracting with licensed cbntra.ctors to construct the project (Sec. 7044 Business and Professions
Code: The Contractor's License Law does not apply to an owner of propertyv'ho builds or improves thereon, and who contracts for sudl projects With
1i-Qontractor(s) licensed" pursuant to the Contractor's License Law}" .
U I am exempt under See, - , B & P.C. for this reason:
Date: Owner:
I WORKER'S COMPENSATION DECLARATION
I hereby affinn" under penalty of perjury one of the following declarations:
o -) have and win ma intaln a certificate of conse~t to self-insure for worker's compensation,
as provided for by Sedion 3700 of the Labor Code, for the performance of,the, work far which
"',this permit is issued. . _" "
~ve and will maintain worker's 'compensation insurance, as required by'Sect,l0n.3700 of 311/2005"
the Labor Code, for the performance of the work for which this permit is issue:d. .Myworker;s Date:
Compensation insurance carrier and policy are:
Carrier: STATE COMPENSATION FUND Policy Number. 046-0008414
. BUILDING PERMIT NO. BLD2005-00522
TYPE OF PERMIT
De.molition CITY
DATE: 3/1/2005
JOB ADDRESS: 1001 W LINCOLN AVE
LEGAL DESCRIPTION: TR 254 LOT 7 ALL -EX ST-
APPLICANT: SHERMAN GILSON
OWNER INFORMATION:
Christophe R Ryan
.1001 W Lincoln Ave
Anaheim, CA 92805
BUILDING DIVISION
200S. ANAHEIM BLVD.
(714} 765 - 5153
INSPECTION REQUEST LINE:
(714} 765 - 4626
CENSUS CODE: 437
QUARTER SECTION: 62
ARCHITECT/ENGINEER INFORMATION:
PROCESSED BY: MJF
-.-J
This section need not be compl.eted if the pennit is for one hundred dollars ($100) or less.
o I certify tha't in the perfonnance of the'work -for which this permit is ,issue~, I shci U not .
employ any person in any manner so asto become subject to theworkers compensation laws
of Califomia, and agree that if I should baeo ~e oth worker's compepsation
provisions of Section 3700 of the Labor COd s all 0 h ::lZ..:~ tho~e provisions.
Date: 3/1/2005 Applicant
WARNING: FAILURE TO SECUR ORKER'S C PENSATION.COVERAGE IS
UNLAWFUL, AND SHALL SUBJ T AN EMPLOYER TO CRIMINAL PENALTIES AND CIVil
FINES UPTO ONE HUNDRED OUSAND DOLLARS ($100,000), IN ADDITlON TO THE
COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE
LABOR CODE, INTEREST AND ATTORNEY'S FEES.
I CONSTRUCTION LENDING AGENCY _
j hel~by a,ffirm unaer ~nariy uf perju,y tirat iht:re-j$ a con::.U'uciion iendiilg-ag..tnCy {cr l:'~
performance of the work for whidl this permit is issued {Sec.3097 ,Civ.C}:
Lender's Infonnation:
I certify t~atJ have read, thi$ application and state that the above information is correct I
agree to comply with_all city ordinances and state laws relating to building coristruction. and
h' by 0 iZe epre ntive f this city to enter upon the above mentioned property for
i spe r se. "
Date: 3/112005
ignat re of Applicant or Agent
The permit sh I expire by limitation and become null and void if the building or
work has not p.assed final inspection 365 days from the date of permit issuance. A
new permit is required to commence or continue work.
LICENSED CONTRACTORS DECLARATION
I hereby affirm under penalty of perjury that I am
licensed under. p." 'sians of chapter 9 (commencing
. with Section.7 f ft Business and'
. Professions
NUMBER
252618
TYPE'
TYPE
~
Contractor
EXPIRATION DATE
7/3112006
C21 HOU
C21 CRAN
Construcion Tvpes:...
VN" .
Fees f.?aid for Permit:
Total:
393.40
INSPECTION RECORD
INSPECTION 'CATE INSPECTOR
Temporary Power Pole
Plumbing (DralnlWaste Pipe) . .'
Electrical Ground Electrode/uter .
SetbacklF.ormsfTrench!!S (Footings)
Do noUns tall subfloor or pour floor slab until the
foUowing applicable items have been signed: .
Plumbing (Water Pipe.Sprinkler Valves)
Mei:hanical (GroundWork)
Electrical (Underground Conduit)
Pre-slab (CompactlonlMeITlbrane.Relnf.
Underpinning (Roar Joist/Girders) .'
Do not cover or conceal tbe work below until the ....
foUowing applicable items have been signed:. .
1 st Floor Shear . .
Flresprinkler . (Rough) .
2nd Floor Shear . .
Roof (Sheathina/Diaphraam'Frame) .
Masonry (ReinfJBOnd Ileam/Pre-Grout)
Rough Plumbing (Top Out) .
Rough Mechanical .
ROugh eectrl!:al III .
Rough Electrical
. Framing (Only'after Plbg..Elec.,"_Mech:. and Fire) .
Insulation (SoundlEnergy)
po not tape or pla(lter until the following applicable'
Items hav.e been signed: . . .'
Drywall . .
Penetrations (Fire Rated) Electrical
Penetrations (Fire Rated) Mechanical .
Penetrations (Fire Rated) Plun1blng . . .
Interior Lath . .
Exterior Lath . ;, '
. GENERAL ITEMS
. exterior Plaster (Brown Coat)
T -Bar Electrical'
T -Bar Mechan,ical
'T'Bar Structural' . . .
Sewer' fAr4:,r I/~
Water Engineering Backflow . j
Water Servic.. . .
FINAL INSPECTIONS Date · Inspector
Electrical Final
Plumbing Final .
Mechanical Final . I .
Gas Test
Engineering/Grading Final 765-5126
~ .
Fire Dept. Final 765-4040
Water Engineering 765-5268 . .
Sub List/Business License 765-519
Zoning 765-5139 '. .'
Building Final ~ast inspection- Oniy ~j~il 1/).."7
fter Above Complete)
PARTIAL INSPECTIONS ~/
Buildinq Inspections
Mechanical Inspections
. Plumbinq Inspections.
Electrical Inspections
~
SOOTH COAST AIR QUAUrV lIlIAMGlEilIllENr DISTIRIC1"
NOTIFICATIO!\'I OF DEMOLITION OR-ASBESTOS IBIOVAL
'~..~'.)i. :
iIIlAII. FOIlIIi MD FEE TO SCAQIIlo. ASBESTOS NOTIFICATIONS, FILE' 55lI41, LOS MGELES CA 9007441141
AQI/lD USE ONLY SCREEN BY RECEIVED POSTMARK ENTERED BY NOTIFICATION #
COMPLETED8Y C/taJfJe L Clark COMPANY Three D SerIi:e Company, Inc. PHONE 909/469-2800 I
DATE 02/10/05 CHECK# 7843' FEE$ 112.80 PROJECT# D23-1 675
MOTIFICATlON TYPE ~ REvIsION DATES REvIsION OrneR (hlghlighl) CANCEllATION
PROJECT 1YPE 0RIlERe0 IlEMourION RENOVATION (removal) EMERGENCY REMoVAL PlANnED RENo (annual)
SITEII\IFOIlllATIOl\l SITE NAME 1001 W. Lincoln, Anaheim, CA
SITE ADDRESS 1001 W. Lincoln, Anaheim, CA CROSSSTREET Carleton
CITY Anaheim STATE CA ZIP 92802 COUNTY Orange
DESCRIBE WORK AND LOCATION Demolish and remove improvemen1s
BUIlDING SIZE (sa FT) 2,500 NUMBER OF FLOORS 2 BUILDING AGE (YEARS) 40 + NUMBER OF DWEWNG UNITS 2
I!I.DG I'IlIOR/I'IlEllEIIlT US!; ~ HOSPITAL INDUSlRIAL Other OFFICE PuBUC BLDG. HOUSE SCHoot. SHIP UNNiCOUEGE
SITE OWNER Ci ty of Anaheim,Anaheim Redev.MIDRESS 201 S. Anaheim Blvd. STE 1003
CITY Anaheim STATE CA ZIP 92805 CONTACT steven Stoewer PHONE 714/765-433
REQUIRED IlUILDlI\lG ASBESTOS YES @: ASBESTOS @> NO ASBESTOS @NO BUILDING TO BE @ NO
INFORDfIATlDN PRESENT? SURVEY?' REMOVED? DEMOUSHED?
PROJECT DATES . START 02/28/05 END 03/14/05 WORK SHI~swing, night)
ASBESTOS moum TO lIE FRIABLE CLASS I CLASS II TOTAL AiIlOUNT (add row)
REIIIIOVED Qn square feel) M/A
ASBESTOS REIIIIOVAl. FROIIII SURFACES PIPES COMPONENTS
AiIlOUNT OF EACH TYl'E OF ACOUSTIC CEIUNG UNOLEUM INSULATION FIRE PROORNG DUCTING STUCCO MASTIC
ASBESTOS pn square feel)
FLOOR TILES (VAT) DRY WALL PLASTER TRANSITE ROOFING OTHER
(describe)
CoMmACTOR INf'OUilT801\l CSLB UCENSE I/- 252618 OSHAREG# NIA AQMD 10 I/- 82245
NAME Three D Service Company, Inc. ADDRESS 1551 East Mission Blvd.
CITY Pomona STATE CA ZIP 91766 SITESUPVRGreg Gilson PHONE 90914894llOO
WAlITE TRI\I\lSI'IlRTER 111 NIA LAIIlDFlLL Olinda Landfill
ADlY.~ESS ADDRESS 1942 Valencia Ave.
CITY STATE I ZIP CITY Near Brea I STATE CA TZlP 92621
CertifiedM.aillNo.: 7004 0750 0002 6587 8669
, Asbestos surveys are required jlfior to Demolition and Renovation
Page1of2
SCAQR//I) NOTIFICATION OF DEIIOLITION OR ASBESTOS REMOVAL
IWAU. FORiI AIID FEE TO SCAQIIID, ASBESTOS NOTIFICAnoNS. FII.E 'li5841, LOS ANGELES CA llOO74-5141
"
WASTE TRAl\lSPORTER #2 M/A WASTE STORAGE SITE N/A
ADDRESS ADDRESS
CITY STATE ZIP CITY STATE ZIP
CONTROLS: DESCRIBE WORK PRACTICES AND CONTROLS TO BE USED AT THE RENOVATION AND DEMOUTlON SITE. Procedure' 1, 2, 3, 4, 5 or OIlIer.
Demolish and I8IIIDVe buildng with labor and equipment
For asbesfos lllIIIovals elide the comblnallon of Rule 1403 pnx:edtJres 1IIed. Procedure 4 and 5 sulmft plans for AQMD prior approval.
~~ DETECTION PROCEDURE: CIRCLE THE PROCEDURES AND ANALYnCALMETHODS USED TO DETERMINE ASBESTOS IN THE BUILDING:
urvey, ulk llampllng;Jnspecllon, P~, TEM, Assumed as AsbesfIlS.PACM, Describe Ofher. ,
FOR DEIIOLnIONS GIVE THE COMPANY NAME AND DATES OF THE ASBESTOS REMOVAl.: Vi si ons West 02/24/05-02/28/05
FOR ORDERED DEIIOLITION SEND A COPY OF THE ORDER AND GIVE THE AGENCY NAME & PHONE II N/A
AUTHORIZING PERSON: TITLE
DATE OF ORDER: I DATE ORDERED TO BEGIN:
FOR EMERGENCY ASBESTOS REIIlOVAL GIVE THE NAME AND PHONE NUMBER OF THE PERSON DECLARING/AUTHORIZING THE EMERGENCY, DATE AND HOUR OF
EMERGENCY AND DESCRIBE THE SUDDEN, UNEXPECTED EVENT: N/A
EXPlAIN HOW THE EVENT WOULD CAUSE UNSAFE CONDmON8, EQUIPMENT DAMAGE OR UNREASONABlE FINANCiAl BURDEN:
CONTIIIIGEMCY PLAN: DESCRIBE ACTIONS TO BE FOllOWED IF UNEXPECTEO ASBESTOS IS FOUND DURING DEMOlITION OR ASBESTOS MATERIAl BECOME
DISTURBED, CRUMBLED, PULVERIZED, OR REDUCEO TO POWDER. Project wiD be stopped and owner notified to cordacIlhe Abatement CClIltractor
TRAINING CERTlFlCAnoN: I ceIIIly lbat an lndlvldual1rained in the provisions of regulallon AQMD Rule 1403 and NESHAP win be on slIe during the removal and
evidence thal 1Ite required lIlIining has been accomplished by this ~?~g noonal business hOlllS. Dale 02/1 0/0
Company Name: Print name of 0lI/II8l/0perat0r S alure of owneiIoperator Tittle of owner/operator
Three D SeIvIce Company, Inc. Charlie L Clark President
IIIlFORllQATIOIll CERTIFICATION: I certilythal the above infonnatfon ~-Z~aUachmen1s. Dale02/10/0
Company Name: Print name of owner/operator Signature of aomerI< TdIle of owner/operator
Three D Service Company, Inc. Chanle L Clark President
NotifIcaIIons can not be accepted without the required fee (AQMD Rule 301), Asbestos removals of less than 100 square feet are exemJtfrom notllicallon and fees.
Please make checlcs payable to 'SCAQMD". Fees are per notification, not refundable, and vary a:cording to the projeclsiza Fees are as follows:
PROJECT SIZE in 1l" DEMOUTlON OR REMOVAL PROCEDURE 4 or 5 PlAN SERVICE CHARGE
1,000 or less $ 36.00 $ 450.91 Special Handling Fee $ 36.00
1,001 to 5,000 $112.80 $ 526.81 Revision 10 NolIflcatIon $ 36.00
5,001 to 10,000 $ 264.03 " $ 678.04 Returned Check Fee $ 2g,28
10,001 to 50,000 $414.01 $ 828.02 Planned Renoya1lon $ 408.38
50,00110 1oo,IJOO--..4 600.00 $ 1,014.01
100,001 or more $ 1,000.00 $1,414.01
ATTEMTUOIll: Keep a cOpy of your nollflGllIlIlil. state law requires thai you provide a copy of the demo/b noliflcalion to Building and Safety before issuance10f a
demolltlon pennlt For questions ca/11lfJ9.396.2336. For your convenience please mail the fann and fee and do not hand cany to AOMO.
~
5
OOAIL FOIlllll AI\ID FEE TO: SCAQlWO, ASBESTOS MOTIFICATlONI!, FILE S 55641, LOS AIIlGElES CA 90074-5641.
TELIEPHOI\lE: (909) 396-2336 FAX: 19f19) 396-3342
Forms, instructions, and Rule 1403 are available at AQMO's web sfte _.aqmll,go1l
SCIlOIIIIIII.I~ .2 2111A.~ ConI". Drilll! mamnnd BAr (,;A !l17A.'>.41R7 /!lOO1 ::l!IR-?IlIlO
Page 2 of2
Fann REV 21lO30627
. Complete items 1. 2. and 3, Also complete
item 4 if Restricted Delivery is desired.
II Print your name and address on the reverse
so that we can return the card to you.
. Attach this card to the back of the mailpiece.
or on the front if space penn its.
1. Article Addressed to:
SCAQMD
ASBESTOS NOTIFICATIONS
FILE #55641
LOS ANGELES CA 90014-5641
023 - I k, 7S'
,J- /0- 05'
2. Article Number
(Transfer from service/abel)
PS Form 3811, August 2001
3. Sel'\lice Type
~Certified Mail 0 Express Mall
o Registered 0 Return Receipt for Merchandise
o Insured Mall 0 C.O.D.
4. Restricted Delivery? (Extra Fee) 0 Yes
7004 0750 0002 65&7 &669
Domestic RetUrn Receipt
10259s.G2-M-1540}