HomeMy WebLinkAboutTI-20-0243 „ •.ti City of Arcadia, CA Permit NO.11-20-0243
Development Services Department Permit Type:Tenant Improvement
240 West Huntington Drive,Post Office Box 60021
f Arcadia,CA 91066-6021 Work Classification:Tenant Improvement
(626)574-5416
Permit Status:Issued
ARCAUTA Issue Date:06/26/20201 Expiration: 06/28/2021
,
Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number
1401 S BALDWIN AVE Arcadia, CA 91007-7922 5383031032
-nn1110111os.1111. VIIIIIIININEM
Contacts
HNS BALDWIN LLC C/O LISA LAU AND CO Owner JACOB WEBSTER Applicant
INC 1236 POTOLA AVE,TORRANCE,CA 90501
1401 S BALDWIN AVE (310)702-7852 WEBSTERJACOB@AOL.COM
ELEVEN WESTERN BUILDERS INC Contractor
2862 EXECUTIVE PL,ESCONDIDO,CA 92029
(760)796-6346 439908
11011111111111111111111111,
I.
Description: INTERIOR T.I TO EXISTING CVS RETAIL STORE Valuation: $ 100,000.00 Tenant CVS
WITH ADA UPGRADES TO INTERIOR,RELOCATE SHELVING,
NEW CONSULTING ROOM AND PHARMACY AREA. WITH EMP Total Sq Feet: 0.00 Plan Check#20-243 Plan#279
.
Fees Amount Payments Amount Paid
Accessibility Plan Check $119.34 Total Fees $3,858.14
Accessiblity Building Permit $122.40 Cash/Receipt#REC-04827-20 $2,338.84
Add/Alter Ducts $79.52 Cash/Receipt tt REC-03830-20 $1,519.30
Air Handling Units>10,000 cu ft per min. $49.80
Amount Due: $0.00
•
Building Issuing Fee $47.01
Building Permit Fees $1,224.00
BuildingePlanlReview Fee $795.60$ ,-7� m7,.-----..... /
Cal Green Plan Check 579.56 / '���” 9_"—�� -!/w/•�
Commercial T.l.Fire Plan Chk. $280.00
Distribution Panel $32.96
Electrical Permit Issuance Fee $47.01 CALLS FOR INSPECTIONS
Energy Plan Review Fee $244.80 Request for inspection by telephone at 626-574-5450. Leave a message
Fire Final Occupancy Fee $200.00 requesting the address,timeframe and what inspection item is needed.
Green Building Standard 54.00
Lavatories $52.84
Light Fixtures 564.40 This permit/plan review expires by time limitation and becomes null and
Mechanical Permit Issuance Fee 547.01 void if the work authorized by the permit is not commenced within 180 days
Outlets Receptacles&Switches 5188.42 from the date of issuance or if the permit is not obtained within 180 days
Plumbing Permit Issuance Fee $47.01 from the date of plan submittal.This permit expires and becomes null and
void if any work authorized by this permit is suspended or abandoned for 180
Sewer Connection on Property $33.01 consecutive days or if no progressive work has been verified by a City of
Solid Waste Management Fee $6.25 Arcadia building inspector for a period of 180 consecutive days.
Total: $3,858.14
OY .-,1PETE�I
June 26, 2020
Issued By: Date
June 26,2020 Page 1 of 1
A
PERMIT/PLAN REVIEW APPLICATION
as
oEf @@ Development Services Department,240 West Huntington Drive,Post Office Box 60021
Arcadia, CA 91066-6021, (626) 574-5416, Fax (626)447-9173
City of
Arcadia
LICENSED CONTRACTOR'S DECLARATION WORKERS'COMPENSATION DECLARATION
❑ I hereby affirm under penalty of perjury that I am licensed under provisions of I hereby affirm under penalty of perjury one of the following:
Chapter 9(commencing with Section 7000,of Division 3 of the Business and
Professions Code„gnd my license is in full force and effect. ❑ I have and will maintain a certificate of consent to self-insure for workers'
License Class P License No.1-I 3 9903 Exp. Date Si s 1/2 g compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
Signature of Contractor v U
❑ I have and will maintain workers'compensation insurance,as required by Section
OWNER-BUILDER DECLARATION
❑ I hereby affirm under penalty of perjury that I am exempt from the Contractors 3700 of the Labor Code,for the performance of the work for which this permit
License Law for the following reason(Section 7031.5,Business and Professions is issued.My workers'compensation insurance carrier and policy numbers are:
Code.Any city or county which requires a permit to construct,alter,improve, Carrier D Iv iC
demolish,or repair any structure,prior to its issuance,also required the applicant
Policy Number
for such permit to file a signed statement that he or she is licensed pursuant to the
provisions of the Contractors License Law(Chapter 9(commencing with Section (This section need not be completed if the permit is for one hundred dollars or less)
7000)of Division 3 of the Business and Professions Code)or that he or she is
❑ I certify that in the performance of the work for which this permit is issued,I shall
exempt there from 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 not employ any person in any manner so as to become subject to the workers
penalty of not more than five hundred dollars($500)): 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
❑1, as owner of the property, or my employees with wages as their sole forthwith comply with those provisions.
compensation,will do the work,and the structure is not intended or offered for
sale(Section 7044,Business and Professions Code:The Contractors License Date Signature
Law does not apply to an owner of property who builds or improves thereon,
or who does such work himself or herself or through his or her own
employees,provided that such improvements are not intended or offered for WARNING: Failure to secure Workers'Compensation coverage is unlawful,
sale. If,however,the building or improvement is sold within one(1)year of and shall subject an employer to criminal penalties and civil fines up to one
completion,the owner-builder will have the burden of proving that he or she hundred thousand dollars($100,000),in addition to the cost of compensation,
did not build or improve for the purpose of sale). damages as provided for in Section 3706 of the Labor Code, interest, and
attorney's fees.
❑I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project(Section 7044, Business and Professions CONSTRUCTION LENDING AGENCY
Code:The Contractors License Law does not apply to an owner of property
who builds or improves thereon,and who contracts for such projects with a I hereby affirm under penalty of perjury that there is a construction lending agency
contractor(s)licensed pursuant to the Contractors License Law). for the performance of the work for which this permit is issued (Section 3097,
Civil Code).
❑ I am exempt under Section 7044,Business and Professions Code,for this reason:
Lender's Name
Date Signature Lender's Address
IMPORTANT: APPLICATION IS HEREBY MADE TO THE BUILDING OFFICIAL FOR A PERMIT SUBJECT TO THE CONDITIONS AND
RESTRICTIONS SET FORTH ON THIS APPLICATION AND THE FOLLOWING:
1. The City's approved plans and permit inspection card must remain on the job site for use by City inspection personnel.
2. Final inspection of the work authorized by this permit is required.A Certificate of Occupancy must be obtained prior to use and occupancy of new buildings
and structures.
3. Per South Coast Air Quality Management District(AQMD)regulations,renovation and remodeling work that results in the removal,stripping,or altering
of asbestos containing materials requires an astkestos survey and removal prior to disturbing the asbestos. Please contact AQMD at(909)396-2000 for
further information. �C /
Name /7 t j 6 o w z_,yk Le Z Title b C'.) ' - A— 4.0/5 Ir .✓ Ivr<✓r
PRINT NAME
I certify that I have read this application and state that the above information is correct and that I am the owner or duly authorized agent of the owner.
I agree to comply with all City ordinances and State Laws relating to building construction. I hereby authorize representatives of the City of
Arcadia to enter upon the above-mentioned property for inspection purposes.
Signature Date 7/ / / Z c7
NOTES
Building Inspections Date Insp. Plumbing Inspections I Date I Insp. /4(01
100. Setbacks 210. Under fir/bldg.drain t3-7-2.o
101. Rough grade 211. Copper underslab
102. Fi.s.&forms 212. Rou.h.lumbin.
2-0
103. Pre-slab
NEM 213. Rough gas g-2- ��
104. Floor'oists 214. Shower.an _-_-4 )' .4O 4cy 4 1..I4 z,S
105. Steel 215. Water heater
106. Grout lift 216. Roof drains /[•A►"��
107. Shear nailing 217. Building sewer P_. ,,Y, 4- 4 r tPihi A•C
108. Diaph nailing 218. Water service
109. Roof nailin. -WA 4-65 $arra=�� �QYW kl GC- 0,,r219. Final.as
110. Framing .C. tri=220. Fixtures „cF enc o . uc frr
111. Occ./Area Sept.Wall -MBE 221. Final.lumbin. -17-16 r, e3-a.c.) GC�
amu,3i.� c
112. Sound walls -� Sewer ca./demo.
22. �/
ra��6< G T'
113. T-bar.rid ,-I-?�"Z r ,g ,df !�6 ,rC g.03
114. Insulation-Flr. Pool Inspections Date Insp. 4:6) I01I,‘ (..r-0,7 -Saawr j
115. Insulation-Wall 240. Excavation/steel /s✓
116. Insulation-Ceil. 241. Rough plumbing
117. Drywall nailing 242. Light shell!bonding
118. Interior lath 243. Underground conduit
119. Exterior lath 244. P-trap
120. Finish grade 245. Gas line&test
121. Final building "47-Zp 246. Fence,gates&signs
122. Final demorlot clear 247. Pool heater
248. Final electric
Electrical Inspections Date Insp. 249. Final.lumbin.
150. Power pole 250. Pool cover
151. Sales lot lighting 251. Pool final
152. Under.round conduit
153. Underslab conduit Reroof Inspections Date Insp.
154. LI ER ground 270. Pre-reroofinsp. -�
155. Water ground 271. Roofoofframin.
156. Rou.h electrical 272. Sheathin. nailin.
158. Fixtures 1--.44./Z. ' -/-'l'.s 273. Final reroof --
158. G.F.C.I.
159. E..t.bondin. Sign Inspections I Date I Insp.
160. Service panel 80. Setback/overhang
161. Final electric 14 7-46 281. Footing
282. Conduit/wirin.
Mechanical Inspections Date Insp. 283. Disconnect --
180. Venting/flue --284. Final sign --
181. Furnace/A.C.Furnace/A.C.
182. Rouch HVAC Miscellaneous Insp. Date Insp.
183. Fire dampers 290. Fire alarm
184. Furnace compartment 291. Underground supply
185. Combustion air 292. Fire sprinklers
186. Smoke detectors 293. Monitor system
187. Metal F.P.rough 294. Hood dry chem.
188. Compressor setback 295. Final
189. Commercial hood
190. Duct shaft Sewers&Offsite Insp. I Date I Insp.
191. Final mechanical --300. Lateral(main to P/L) --
301. Saddle/Y
Block Wall Inspections Date Insp. 302. Cess.so'filled
200. Footings 303. Sidewalk
201. Steel/rebar 304. Driveway
202. Grout lift 305. Curb replacement
203. Final wall 306. Trash bin
•�. City of Arcadia, CA Permit NO.11-20-0347
Development Services Department Permit Type:Tenant Improvement
240 West Huntington Drive,Post Office Box 60021
Arcadia,CA 91066-6021 Work Classification:TI-Racks
(626)574-5416 Permit Status:Issued
A1ZC D t Issue Date:07/01/2020 I Expiration: 07/01/2021
,
• Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number
1 1401 S BALDWIN AVE Arcadia, CA 91007-7922 5383031032
Contacts •
fHNS BALDWIN LLC C/O LISA LAU AND CO Owner JACOB WEBSTER Applicant
I INC 1236 POTOLA AVE,TORRANCE,CA 90501
1401 S BALDWIN AVE (310)702-7852 WEBSTERJACOB@AOL.COM ,
ELEVEN WESTERN BUILDERS INC Contractor
2862 EXECUTIVE PL, ESCONDIDO,CA 92029
1 '760)1796-6346 439908
epwrrrr® • 11111rrt_ ....1
Description: INSTALL OF STORAGE RACKS IN PHARMACY AREA [Valuation: $ 20,000.00 Tenant
I ONLY AT CVS
Total Sq Feet: 0.00 Plan Check#20-347 Plan#
-
ntausiiimmosiw
Frees Amount Payments Amount Paid
Accessibility Plan Check $39.42 Total Fees $1,193.86
Accessibiity Building Permit $40.43 Cash/Receipt#REC-04873-20 $504.54
Building issuing Fee $47.01 Cash/Receipt#REC-03998-20 $689.32
Building Permit Fees $404.25
Amount Due: $0.00
Building Plan Review Fee $262.77
Cal Green Plan Check $26.28
Commercial T.I.Fire Plan Chk. $280.00 �; Q
Energy Plan Review Fee $80.85 # '�� 1—i7-2-t> L'fi
Green Building Standard $1.00
Solid Waste Management Fee $6.25
Strong Motion Inst.Program Corn $5.60 CALLS FOR INSPECTIONS
Request for inspection by telephone at 626-574-5450. Leave a message
Total: $1,193.86 requesting the address,timeframe and what inspection item is needed.
This permit/plan review expires by time limitation and becomes null and
void if the work authorized by the permit is not commenced within 180 days
from the date of issuance or if the permit is not obtained within 180 days
from the date of plan submittal.This permit expires and becomes null and
void if any work authorized by this permit is suspended or abandoned for 180
consecutive days or if no progressive work has been verified by a City of
Arcadia building inspector for a period of 180 consecutive days.
0 �"U' L.L I Y i
July 01, 2020
Issued By: Date
July 01,2020 Page 1 of 1
F AR
`rJFOR ,'
4111631, i PERMIT/PLAN REVIEW APPLICATION
OA '—'7« x`10
E4#11/• Development Services Department,240 West Huntington Drive, Post Office Box 60021
„a 0. `� Arcadia, CA 91066-6021, (626) 574-5416, Fax (626)447-9173
City of
Arcadia
CENSED CONTRACTOR'S DECLARATION WORKERS'COMPENSATION DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of I hereby affirm under penalty of perjury one of the following:
Chapter 9(commencing with Section 7000,of Division 3 of the Business and
Professions Code,and my license is in full force and effect. ❑ I have and will maintain a certificate of consent to self-insure for workers'
License Class 13 License No. '1 39 9 43 Exp. Date 5f3//1 4 compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
Signature of Contractor ,...-/-[2 y-
I have and will maintain workers'compensation insurance,as required by Section
OWNER-BUILDER DECLARATION
0 I hereby affirm under penalty of perjury that I am exempt from the Contractors 3700 of the Labor Code,for the performance of the work for which this permit
is issued.My workers'compensation insurance carrier and policy numbers are:
License Law for the following reason(Section 7031.5,Business and Professions
Code.Any city or county which requires a permit to construct,alter,improve, Carrier 2 " t2'. r- - R `~"C.-it r t,A
demolish,or repair any structure,prior to its issuance,also required the applicant
Policy Number W C 3 0 L 9 4 I d 0
for such permit to file a signed statement that he or she is licensed pursuant to the
provisions of the Contractors License Law(Chapter 9(commencing with Section (This section need not be completed if the permit is for one hundred dollars or less)
7000)of Division 3 of the Business and Professions Code)or that he or she is
exempt there from and the basis for the alleged exemption. Any violation of ❑ I certify that in the performance of the work for which this permit is issued,I shall
Section 7031.5 by any applicant for a permit subjects the applicant to a civil not employ any person in any manner so as to become subject to the workers'
penalty of not more than five hundred dollars($500)): 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
0 I, as owner of the property, or my employees with wages as their sole forthwith comply with those provisions.
compensation,will do the work,and the structure is not intended or offered for
sale(Section 7044,Business and Professions Code:The Contractors License Date Signature
Law does not apply to an owner of property who builds or improves thereon,
or who does such work himself or herself or through his or her own
employees,provided that such improvements are not intended or offered for WARNING: Failure to secure Workers'Compensation coverage is unlawful,
sale.If,however,the building or improvement is sold within one(1)year of and shall subject an employer to criminal penalties and civil fines up to one
completion,the owner-builder will have the burden of proving that he or she hundred thousand dollars($100,000),in addition to the cost of compensation,
did not build or improve for the purpose of sale). damages as provided for in Section 3706 of the Labor Code, interest, and
attorney's fees.
❑I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project(Section 7044, Business and Professions
Code:The Contractors License Law does not apply to an owner of property CONSTRUCTION LENDING AGENCY
who builds or improves thereon,and who contracts for such projects with a I hereby affirm under penalty of perjury that there is a construction lending agency
contractor(s)licensed pursuant to the Contractors License Law). for the performance of the work for which this permit is issued (Section 3097,
Civil Code).
❑ I am exempt under Section 7044,Business and Professions Code,for this reason:
Lender's Name
Date Signature Lender's Address
IMPORTANT: APPLICATION IS HEREBY MADE TO THE BUILDING OFFICIAL FOR A PERMIT SUBJECT TO THE CONDITIONS ANI)
RESTRICTIONS SET FORTH ON THIS APPLICATION AND THE FOLLOWING:
1. The City's approved plans and permit inspection card must remain on the job site for use by City inspection personnel.
2. Final inspection of the work authorized by this permit is required.A Certificate of Occupancy must be obtained prior to use and occupancy of new buildings
and structures.
3. Per South Coast Air Quality Management District(AQMD)regulations,renovation and remodeling work that results in the removal,stripping,or altering
of asbestos containing materials requires an asbestos survey and removal prior to disturbing the asbestos. Please contact AQMD at(909)396-2000 for
further information. '!; ,� e,� f
,,1
Sid , .a
r s Ir•.
•
Name i IAA, 6v.vifAr,.l' .: .,t Title & .e--... wt k' Sip-eve. .iv*n.p74.
PRINT NAME
I certify that I have read this application and state that the above information is correct and that I am the owner or duly authorized agent of the owner.
I agree to comply with all City ordinances and State Laws relating to building construction. I hereby authorize representatives of the City of
Arcadia to enter upon the above-mentioned property for inspection purposes.
Signature -2)'') - Date -7/ // Z 0
+,; City of Arcadia, CA Permit NO. FIRE-20-1016
Development Services Department Permit Type:Fire
240 West Huntington Drive,Post Office Box 60021
Arcadia,CA 91066-6021 Work Classification:Fire Sprinkler
(626)574-5416
Permit Status:Issued
ARCADIA Issue Date:07/09/20201 Expiration: 07/09/2021
Addr NO. Dir Prefix Street Name Street Suffix Unit City,State,Zip Parcel Number
1401 S BALDWIN AVE Arcadia, CA 91007-7922 5383031032
L
Contacts
HNS BALDWIN LLC C/O LISA LAU AND CO Owner RBM FIRE PROTECTION INC* Contractor
INC 23597 ANCASH CT, PERRIS,CA 92570
1401 S BALDWIN AVE (951)657-8899 1039605
Description:FIRE SPRINKLER FOR TI. 6 ADDED SPRINKLERS 17 Valuation: $ 12,500.00 Tenant
RELOCATED SPRINKLERS
Total Sq Feet: 0.00 Plan Check#20-1016 Plan#
Fees Amount Payments Amount Paid
Fire Issuance $47.01 Total Fees $1,035.36
Fire Permit Fees $287.35 Cash/Receipt#REC-04936-20 $1,035.36
Solid Waste Management Fee 2 $1.00
Amount Due: $0.00
Sprinkler Heads $700.00
Total: $1,035.36
z 7N, CI f 7-Za
CALLS FOR INSPECTIONS
Request for inspection by telephone at 626-574-5450. Leave a message
requesting the address,timeframe and what inspection item is needed.
This permit/plan review expires by time limitation and becomes null and
void if the work authorized by the permit is not commenced within 180 days
from the date of issuance or if the permit is not obtained within 180 days
from the date of plan submittal.This permit expires and becomes null and
void if any work authorized by this permit is suspended or abandoned for 180
consecutive days or if no progressive work has been verified by a City of
Arcadia building inspector for a period of 180 consecutive days.
July 09, 2020
Issued By: Date
July 09,2020 Page 1 of 1
F AR
cpo ORN,
4 � l PERMIT/PLAN REVIEW APPLICATION
. r....
Development Services Department, 240 West Huntington Drive,Post Office Box 60021
��
, Arcadia, CA 91066-6021, (626) 574-5416, Fax (626)447-9173
City of
Arcadia
LICENSED CONTRACTOR'S DECLARATION WORKERS'COMPENSATION DECLARATION
4 I hereby affirm under penalty of perjury that I am licensed under provisions of I hereby affirm under penalty of perjury one of the following:
Chapter 9(commencing with Section 7000,of Division 3 of the Business and
Professions CoAe,and my license is in full force and effect. ID I have and will maintain a certificate of consent to self-insure for workers'
License Class L�( License N '.-Exp. Date'��✓)�� compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
Signature of Contractor
OWNER-BUILDER DECLARATION Y,b I have and will maintain workers'compensation insurance,as required by Section
❑ I hereby affirm under penalty of perjury that I am exempt from the Contractors 1"t 3700 of the Labor Code,for the performance of the work for which this permit
License Law for the following reason(Section 7031.5,Business and Professions is issued.My workers'compe(�nsaltlion�insurance carrier and policy numbers are:
Code.Any city or county which requires a permit to construct,alter,improve, Carrier Co_
,tet -t►L . Jt
al-
demolish,or repair any structure,prior to its issuance,also required the applicant
Policy Number J/-t�J S-1419 or)
for such permit to file a signed statement that he or she is licensed pursuant to the
provisions of the Contractors License Law(Chapter 9(commencing with Section (This section need not be completed if the permit is for one hundred dollars or less)
7000)of Division 3 of the Business and Professions Code)or that he or she is
exempt there from and the basis for the alleged exemption. Any violation of 0 I certify that in the performance of the work for which this permit is issued,I shall
Section 7031.5 by any applicant for a permit subjects the applicant to a civil not employ any person in any manner so as to become subject to the workers'
penalty of not more than five hundred dollars($500)): 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
0 I, as owner of the property, or my employees with wages as their sole forthwith comply with those provisions.
compensation,will do the work,and the structure is not intended or offered for Date ()Mpg 12VZJ Signatu
sale(Section 7044,Business and Professions Code:The Contractors License
Law does not apply to an owner of property who builds or improves thereon,
or who does such work himself or herself or through his or her own
employees,provided that such improvements are not intended or offered for WARNING: Failure to secure Workers'Compensation coverage is unlawful,
sale. If,however,the building or improvement is sold within one(1)year of and shall subject an employer to criminal penalties and civil fines up to one
completion,the owner-builder will have the burden of proving that he or she hundred thousand dollars($100,000),in addition to the cost of compensation,
did not build or improve for the purpose of sale). damages as provided for in Section 3706 of the Labor Code, interest, and
attorney's fees.
❑I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project(Section 7044, Business and Professions
Code:The Contractors License Law does not apply to an owner of property CONSTRUCTION LENDING AGENCY
who builds or improves thereon,and who contracts for such projects with a I hereby affirm under penalty of perjury that there is a construction lending agency
contractor(s)licensed pursuant to the Contractors License Law). for the performance of the work for which this permit is issued (Section 3097,
Civil Code).
0 1 am exempt under Section 7044,Business and Professions Code,for this reason:
Lender's Name
Date Signature Lender's Address
IMPORTANT: APPLICATION IS HEREBY MADE TO THE BUILDING OFFICIAL FOR A PERMIT SUBJECT TO THE CONDITIONS AND
RESTRICTIONS SET FORTH ON THIS APPLICATION AND THE FOLLOWING:
1. The City's approved plans and permit inspection card must remain on the job site for use by City inspection personnel.
2. Final inspection of the work atit'hor ze 1 byit, s,permit is required.A Certificate of Occupancy must be obtained prior to use and occupancy of new buildings
and structures.I
ate'a 'l ! 'r''';lbi .'"�
3. Per South Coast Air Quality ar e Oil 'i&QMD)regulations,renovation and remodeling work that results in the removal,stripping,or altering
of asbestos containing materials requires an asbestos survey and removal prior to disturbing the asbestos. Please contact AQMD at(909)396-2000 for
further information.
�,� �p
Name --' ` ld,i. `Y\P(�d.�. , Title 6 teC
PRINT NAME
I certify that I have read this application and state that the above information is correct and that I am the owner or duly authorized agent of the owner.
agree to comply with all City ordinances and State Laws relating to building construction. I hereby authorize representatives of the City of
frcadia to enter upon the above-mentioned property for inspection purposes.
Signature 1 1 Date 15-- -\04\1,22'