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Home My WebLink About1044 CARLSBAD VILLAGE DR; ; CB072404; Permit09-18-2007 City of Carlsbad 1635 Faraday Av Carlsbad, CA 92008 Demolition Permit Permit No CB072404 Building Inspection Request Line (760) 602-2725 Job Address Permit Type Parcel No Occupancy Group # Dwelling Units Bedrooms Project Title 1044 CARLSBAD VILLAGE DR CBAD DEMO Full Demo 2033204700 Lot # Reference # 0 Structure Type 0 Bathrooms CHEVRON STATION DEMO STATION & REMOVE TANKS Applicant WAYNE PERRY CONSTRUCTION 8301 COMMONWEALTH AVE BUENA PARK CA 90621 714 826035 Status Applied Entered By Plan Approved Issued Inspect Area ISSUED 09/18/2007 MDP 09/18/2007 09/18/2007 Owner SONNEMAN ROBERT H LIVING TRUST 03 01 06 ET AL 52 EL SERENO CT SAN FRANCISCO CA 94127 Building Permit Plumbing Fee Other Fee Additional Fees TOTAL PERMIT FEES $2000 $1000 $3000 $000 $6000 Total Fees $60 00 Total Payments To Date $60 00 Balance Due $000 Inspector Clearance NOTICE Please take NOTICE that approval of your project includes the Imposition of fees abdications reservations or other exactions hereafter collectively referred to as fees/exactions You have 90 days from the date this permit was issued to protest imposition of these fees/exactions If you protest them you must follow the protest procedures set forth in Government Code Section 66020(a) and file the protest and any other required information with the City Manager for processing in accordance with Carlsbad Municipal Code Section 3 32 030 Failure to timely follow that procedure will bar any subsequent legal action to attack review set aside void or annul their imposition You are hereby FURTHER NOTIFIED that your right to protest the specified fees/exactions DOES NOT APPLY to water and sewer connection fees and capacity changes nor planning zoning grading or other similar application processing or service fees in connection with this project NOR DOES IT APPLY to any fees/exactions of which you have previously been given a NOTICE similar to this, or as to which the statute of limitations has previously otherwise expired PERMIT APPLICATION CITY OF CARLSBAD BUILDING DEPARTMENT 1635 Faraday Ave Carlsbad CA 92008 FOR OFFICE USE ONLY PLAN CHECK NO EST VAL Of Plan Ck Deposit. Validated By Date lo4-4 Address (include Bldg/Suite #)Business Name (at this address) .egal Descnption203-? 20-47 Lot No Subdivision Name/Number Unit No Phase No Total # of units Assessor's Parcel #GAS Existing Useaf ' Proposed Use Descnption of Work SO. FT # of Stones # of Bedrooms # of Bathrooms s , ~, •;,,!•V » ... ..:?...*.. sb*.: .•;••• ,- —«K$-,-r) ^ 1 $ doer, Fax# State/Zip Telephone # Ji ~^_ _s W C4 <?2o0Q Name Address City State/Zip Telephone # (Sec 7031 5 Business and Professions Code Any City or County which requires a permit to construct alter improve demolish or repair any structure pnor 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 commending 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 civijjjenalty of not more than five hundred dollars [$500])fj/ayxte pig/asy JKV Name Address City ' State/Zip Telephone* State License # ^QO^A-S License ClassA.C^// CIO^ ft, C&l/Qjo City Business License # Designer Name State License # Address City State/Zip Telephone # Workers Compensation Declaration I hereby affirm under penalty of perjury one of the following declarations D I have and will maintain a certificate of consent to self insure for workers compensation as provided by Section 3700 of the Labor Code for the performance of the work for which this permit is issued TSr I have and will maintain worker's compensation as required by Section 3700 of the labor Code for the performance of the work for which this permit is issued My worker's compensation insurance earner and policy number are /in Insurance Company SgQ KB ICuM? MS Co. Policy No &Bl°7I0&(y Expiration Date l///°" (THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS [$100] OR LESS) D CERTIFICATE OF EXEMPTION 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 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 cama&nsation damages are provided for in Section 3706 of the Labor Code interest and attorney s Jees SIGNATURE C 31?'^? P/L ^— DATE" I hereby affirm that I am exempt from the Contractor's License Law for the following reason D I as owner of the property or my employees with wages as their sole compensation will d 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 through his own employees provided that such 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 did not build or improve for the purpose of sale) D I as owner of the property am exclusively contracting with licensed contractors to construct the project (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 contracts for such projects with contractors) licensed pursuant to the Contractor's License Law) D I am exempt under Section Business and Professions Code for this reason 1 I personally plan to provide the major labor and matenals for construction of the proposed property improvement D YES D NO 2 I (have/have not) signed an application for a building permit for the proposed work 3 I have contracted with the following person (firm) to provide the proposed construction (include name / address / phone number / contractors license number) 4 I plan to provide portions of the work but I have hired the following person to coordinate supervise and provide the major work (include name / address / phone number / /ontractors license number) 5 I will provide some of the work but I have contracted (hired) the following persons to provide the work indicated (include name / address / phone number / type of work) PROPERTY OWNER SIGNATURE DATE WHITE File YELLOW Applicant PINK Finance PERMIT APPLICATION CITY OF CARLSBAD BUILDING DEPARTMENT 1635 Faraday Ave, Carlsbad CA 92008 Page 2 of 2 PERMITS CW Is the applicant or future building occupant required to submit a business plan acutely hazardous matenals registration for or nsk management and prevention program under Sections 25505 25533 or 25534 of the Presley Tanner Hazardous Substance Account Act' D YES B"NO Is the applicant or future building occupant required to obtain a permit from the air pollution control distnct or air quality management district' ETYES D NO Is the facility to be constructed within 1 000 feet of the outer boundary of a school site' D YES B^NO IF ANY OF THE ANSWERS ARE YES A FINAL CERTIFICATE OF OCCUPANCY MAY NOT BE ISSUED UNLESS THE APPLICANT HAS MET OR IS MEETING THE REQUIREMENTS OF THE OFFICE OF EMERGENCY SERVICES AND THE AIR POLLUTION CONTROL DISTRICT I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097(1) Civil Code) LENDER S NAME LENDER S ADDRESS I certify that I have read the application and state that the above information is correct and that the information on the plans is accurate I agree to comply with all City ordinances and State laws relating to building construction I hereby authorize representatives of the City of Carlsbad to enter upon the above mentioned property for inspection purposes I ALSO AGREE TO SAVE INDEMNIFY AND KEEP HARMLESS THE CITY OF CARLSBAD AGAINST ALL LIABILITIES JUDGEMENTS COSTS AND EXPENSES WHICH MAY IN ANY WAY ACCRUE AGAINST SAID CITY IN CONSEQUENCE OF THE GRANTING OF THIS PERMIT OSHA An OSHA permit is required for excavations of 5 0 deep and demolition or construction of structures over 3 stones in height EXPIRATION Every permit issued by the building Official under the provisions of this Code shall expire by limitation and become null and void if the building or work authorized by such permit is not commenced within 180 days from the date of such permit or if the building or work authonzed by such permit is suspended or abandoned at any time after the work is commenced for a penod of 180 days (Section 106 4 4 Uniform Building Code) APPLICANT S SIGNATURE DATE WHITE File YELLOW Applicant PINK Finance City of Carlsbad Bldg Inspection Request For 10/16/2007 Permit* CB072404 Inspector Assignment Title CHEVRON STATION Description DEMO STATION & REMOVE TANKS Type DEMO Sub Type Phone 7143259049 Job Address 1044 CARLSBAD VILLAGE DR Suite Lot 0 p-n^v Location Inspector \ C^> OWNER SONNEMAN ROBERT H LIVING TRUST 03-01-06 ET AL Owner Remarks Total Time Requested By DAN Entered By CHRISTINE CD Description Act Comments 22 Sewer/Water Service \ •V 29 Final Plumbing Comments/Notices/Holds Associated PCRs/CVs Original PC# Inspection History Date Description Act Insp Comments SEP-18-2007 09 44 CHEURON 7146713439 P 01/01 A j^Sempra ("twigy uwny Notice of Service Discontinuance PERMIT DEPARTMENT, CITY OR COUNTY OF Carlsbad SERVICE WILL BE DISCONTINUED TO ADDRESS 1044 Carlsbad Village Dr. Carlsbad CA BY (Date) September 18,2007 El ELECTRIC METER NO 1799851 D GAS METER NO ALL SERVICE LINES WILL BE REMOVED THIS BUILDING CAN BE MOVED OR RAZED AFTER THE ABOVE DATE SAN DIEGO BY PHONE 760-931-7304 DATE September 18, 2007 PM Forms NoticeofServiceOlscontinuance doc Revised 6/20)06 TOTAL P 01 0 City of Carlsbad Building Department A demolition permit may only be issued to the owner of the property or the State Licensed Contractor that is doing the work The contractor must provide use with a letter, signed and dated by the property owner, giving permission for the building to be demolished M The fee for a demolition permit is $60 00 The attached Demolition Asbestos Certification applicatjon must be completed, signed and have the correct square footage of tne structure being demolished, as well as it s use Applicant must provide a letter from San Diego Gas and Electric stating that the utilities have been disconnected Arrange for appropriate Water Authority to remove water meter •unless construction of replacement structure HS to begin shortly Contact the Planning Department at (760) 602-4625 or £02-4629 to determine if the structure is in the Redevelopment area, if it is in the Coastal Zone Contact the Engineering Department at (760)602-2775 or 602-2741 to determine tf a Haul Route or Right-of-Way Permit is required Notify the Fire Department at (760) 602-4666 to see if they need the use of the building for training purposes h \wordtfront cou-uer "-andouts\demoiition permit requirements doc REV April 19 2004 1635 Faraday Avenue • Carlsbad CA 92O08 7314 • (76O) 6O2 27OO Building Counter • (76O) 602 2719 • FAX (76O) 6O2-8558 DEMOLITION ASBESTOS CERTIFICATION ADDRESS /044 USE OF BUILDING TO BE DEMOLISHED SQUARE FEET "gooo _ X NUMBER OF STORES PROPERTY OWNER CH^Cor-r^ L. ADDRESS "^b <SSACg^ST £g(^ ,CM(SR4r> PHONE APPLICANT ADDRESS uS^'** _ PHONE T/4-&7* ' Section 19827 5 of California Health and Safety Code states 4ti part "A demolition permit shall not be issued by any city as to any building or other structure except upon receipt from the permit applicant of a copy of each written asbestos notification regarding the building that has been required to be submitted to the United States Environmental Protection Agency or to a designated state agency, or both, pursuant to Part 61 of Title 40 of the Code of Federal Regulations, or the successor to that part The permit may be issued without the applicant submitting a copy of the written notification if the applicant declares that the notification is not applicable ~io the scheduled demolition project" As applicant for a demolition permit in the City of Carfsbad, I certify that, I have read the excerpt from Section 19827 5 of the Health and Safety Code provided above, the information I have provided on this form is true and correct, and I further certify the following (\J^ On the attached _ pages are copies of all written asbestos notifications regarding the above referenced building that are required to be submitted to the United States Environmental Protection Agency or to Part 61 of Title 40 of the Code of Federal Regulations, or successor to that part ( ) I declare that the written asbestos notification is not applicable -to the ' scheduled demolition project " ' Applicant's Signature Date h \word\front counter r-andouts\oemolition permit requirements ooc 'itV April 19 2004 COB APCD use ONLY CAM OTPGQ ATP P( 10124 OLD C310VE R Phone (858) 586- :fa^*/</ /& NOTIFI r^Completed ny \V/ S?7 3LLUTION CONTROJL DISTRICT^, DAD, SAN DIEGO CA 92131 2650 Fax: 858-586-2651 2zJ^ CATION OF ASBESTOS RENOVATK x-/ fl Jff&/ltva(9Cr Como, lyongmal D Cancellation D NOTIFICATION Q Revision D Change in asoesto (intiidtc cvPfc a^ revision) (grt-atcr cnan 20*40 D Demolition C Ordered Dernc ppmFCT TYPEr H.UJ cu g emergency Removal Q Emergency De FACILITY INFORMATION | Facility Name /^^fff Address /Q fyjj (]/*} .jfWJ ^#^ $~/&Jy'i**J »/<A/h/ If' //#<*> J?s- Postmarx NoDficaaon # Received ree/ Receipt Entered Sector insoector Assigned/Date DN OR DEMOLITION OPERATIONS anv ,<^>Y\?'6£$ L/<9/t/77;e:?£'/>'*^''Z ^£x-Ss"^ Other (soeciry) •^ s amount Q Change in scar/end date sllaon [tr'Kenovatlon 'removal) •molibon D Planned Renovation (annual) C*$z4sisC&a-£f, ^fy^£fj&>£aZ£&x^ Cross Street // f ff f rtf&cAti'G, S'f' Qcy C/p&i/iJjjvf ' 2'°C3de 9<2&&8f Facility Owner /"A-** Address /4/\C*" ^ "" ^ /O /"€.£) Contact ^^^ ^^ Building Size -fsq ft) ^?9fi><^9 Building pnor/present use .t/ifia^J p/t0e?{f!>e-T'S £<*> Sjtfr-i^Ze/fatei* ^/t/^ ^ State f^^. y$ ™*A*6ieo-/A i Zip Code 9^^2-y* fa/sKer phoneNo^r^^^CCT' Building Age (years) , ^t~ Numoer af Floors ,Number of Units ^-___ n Commeraal D Hospital feflndustnal D Office D K 12 School D Public Sldq D House/Condo Q Ship D Umv/Colleqe D Other PROJECT INFORMATION Asoestos Survey Is Asbestos Present' Will the asbestos be rem Berforned'" -^ -^ jZvYes D No KV" E No ^ Yes ^ No ' FnabJe Asbestos Amount to be Surface Aremoved (sq/ln ft) -Facility Cc / Category I Picas "7 ^r^rsn Surface Area /^~p f \ mponent r _ Facility Component Revised Amounts 1 l\f a revision) ! A_<h««rtn^ Removal Start Date ., £?~/,vJ~&'7 , Damolitii Asoestos Removal End Date For revisions only Revised Starr Dare Revised End Date o^/'?"~O'7 Demolltioi For revis Revised S Revised Er Removal Contractor Name/^JS Ca^rfr+er&AC Phone No^ oved' Is the building to be demolished' ^STves D No • ' Category H Pioes <;&Df (Surface Area Total 7^-s5^ Fatality Component in Operation Start D i Operation End Date ons only Qrt Date id Data ate SiZ-m^&kf3* Ucense* SfQlzg*/ Address 2 WO £^J*Jz<s;# ^/ifc/ C WSte«^5^M^X^c^ Slce Supervisor tf/^Sjes-uwS Demolition Contractor j Name J*_Sboae=Ho> Address ,' Cty/State/Zip C$ ' 5E>$Qt^ CSLSUcense* Site Supervisor Asoeatos Survoys are required pnor lo SDAPCD SUBP^RT M fiula 361 O/0-i ana Demolition nowever Uia actual survey is not rwouired tope sutxnitlsa with he notificatkan Paoo 1 of 2 NOTIFICATION OP ASBESTOS RENOVATION OR DEMOLITION OPERATIONS Waste Transporter*! Name /£<, ,,4 S^^jv^^* J^O Address ^^^/^ J'"*' /7/^tyb*;& £As<s/ Oty/Stete/Zip^/^^^y^g^^^s Q0$05~~ Contact Pers°ni^^), Srt-PS&Ut Waste Disposal Site (Landfill) fj Phone k/d&^^^S1 Name /Pz-csS^/Zs?^ Address /^// ^/ /yy^Ws -r&*>^&- J^/" — /)Contact Person /^y^^f P&S Asbestos Detection Procedures jpZr— Survey >2 'JE^ Bulk Sampling t2 /- Waste Transporter*? Wame Address City/State/Zip Contact Person j Phone & /£tZ£./4sy?-*?~r'- "e^s1 && City/State/Zip /fe#-$^_ &# ty/ZtO? Phone (6Z£}<te9-/3gP Check the appropriate procedures and anafyrjcal methods used to detect the presence of ' asbestos containing materials _, Inspection D TEM ^ PLM D Other Describe work practices and engineering controls to be used *^ Water D Amended Water D Roofing Cutting Saws D Hign Pressure Water Blast D Infrared Machines D Cranes (wrecking ball, clamshell bucket) D Zamboni D Bead Blast D Floor Buffer G PCH Check applicable methods below D Demolition w/rooflng materials in place D Skid Loaders/bobcats/Top Loaders usmg sledge hammers, rj Terrn,nator'" jfr. Axes W\ Shovels Q Implosion f D Demolition w/Cat I Ploor tiles in place rj Explosion D IceChippers Q Pry Bars Q Negat,ve A,r Mach.nes O Bulldozer g Fu|| con^nmerK D Intentional Burning g 3 Stage Decon D Backhoes g G/ove Bag f~l Other .... ^r^ /._. — , o For Ordered Demolition provide a copy of the order and complete the information below Agency Name Date of Order Contingency Plan -S^"****- Ic Training Certification wil by Date faA^o? <«• Information Certification I a Dn Date /X/C^rt-7 (0» Authorizing Person Date Ordered to Begin Title Phone Describe actions to be followed If unexpected asbestos is found during demolition or removal or asbestos material becomes distuned, crumbled, pulverized or reduced to oowder *-rfsf~ (^jff^^^S<^^^^&^^J^t^^/^^S'J^f^^^/lOjP^f~(^/^^^^^^ ertlfy tnat an individual trained In the provisions of this regulation (CFR Part si, Subpart M) 1 be on site dunng the removal and evidence that the required training has been accomplished this person will be available for inspection dunng normal business hours. s\,/ it Name //./*» jAi&frv* t ** srtify that the above information is it Name -rT C k £?*-(•,., / ^^-(/^^^//^/ correct / srfl * £fefcT fs^olLwC^^ S^ff \ - Ongmai notifications are to be aubmitred lo the District at least 10 wording days prior *o removal or demolition. Revised notices are to bTsuDrnirted as soon as possible but no later than the original start daw Onginal notifications cannot be accepted without the rwfuired lee(s) (Rule 4011)(2)) however notifications will oe accepted wnnout me required fee provided the Ine is paid prior to he start date of the original notification SDAPCD SUBPAFT M Rule 361 145 Page 2 of 2 Attorneys at Law July 18, 2007 Mr Mark Martin Transaction Manager-Divestments CB Richard Ellis - Chevron Account 145 South State College Blvd , Fourth Floor Brea, CA 92821 Re Chevron Service Station #9-2321 1044 Cdrisoaa Village Dr Dear Mr Martin, First, as we discussed today, this office represents both of the owners of the above- mentioned property, Ms Jane Singh as to an undivided one-half interest and Ms Jane Sonneman, Trustee of the Robert H Sonneman Living Trust as to an undivided one-half interest Per your request, please be advised that Chevron has our clients' permission to proceed with the demolition/removal of the facilities at the above-mentioned location Please proceed with the necessary permitting in order to facilitate the demolition and abandonment at the location You have represented to us that Chevron will be handling all environmental issues involved in this demolition and removal including any and all remedial action that may need to be taken You have further represented that Chevron will not be renewing or extending its lease of the property I have sent a copy of this correspondence to my clients who will be signing it and forwarding it to your office under separate cover If you have any questions or input please feel free to call this office Best Regards, Carl L Dimeff CLD/ao cc J Sonneman, J Singh Sonneman, Trustee of the Robert H Sonneman Living Trust, U/D/T 3/1/06 Jane Singh 85] S CoistHwy 101 Suite 200 • Encimtas Calitorni i 92024 4444 Ph (760)633 1965'Fax (760)633 1844 Attorneys at Law July 18, 2007 Mr Mark Martin Transaction Manager-Divestments CB Richard Ellis - Chevron Account 145 South State College Blvd , Fourth Floor Brea, CA 92821 Re Chevron Service Station #9-2321 1044 Carlsbad Village Dr Dear Mr Martin, First, as we discussed today, this office represents both of the owners of the above- mentioned property, Ms Jane Singh as to an undivided one-half interest and Ms Jane Sonneman, Trustee of the Robert H Sonneman Living Trust as to an undivided one-half interest Per your request, please be advised that Chevron has our clients' permission to proceed with the demolition/removal of the facilities at the above-mentioned location Please proceed with the necessary permitting in order to facilitate the demolition and abandonment at the location You have represented to us that Chevron will be handling all environmental issues involved in this demolition and removal including any and all remedial action that may need to be taken You have further represented that Chevron will not be renewing or extending its lease of the property I have sent a copy of this correspondence to my clients who will be signing it and forwarding it to your office under separate cover If you have any questions or input please feel free to call this office Best Re Carl L Dimeff CLD/ao cc J Sonneman, J Singh Jane Sonneman, Trustee of the Robert H Sonneman t, U/D/T 3/1/06 851 S Coast Hwy 101 Suite 200 • Encimtas • California 92024 4444 Ph (760)633 1965'Fax (760)633 1844 AC-ORD Date (mm/dd/yy) 12/29/2006 Producer Carntung Nguyen SullivanCurtsMonroe Insurance Services 2100 Mam Street Suite 350 Irvine CA 92614 949 250 7172 www SullivanCurtisMonroe com License # OE83670 Insured Wayne Perry Inc 8281 Commonwealth Ave Buena Park CA 90621 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW INSURER A American International Specialty Lines •' INSURER B Commerce & Industry INSURERc Golden Bear Insurance INSURERD SeaBnght Insurance Company INSURER E IE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS NSf LTR TYPE OF INSURANCE POUCY NUMBER EFFECTIVE MM/PIDATE•~D/YY POUCYEXPIRATION MM/DD/YY LIMITS . LIABILITY (COMMERCIAL GENERAL IMB IciAlMS MADE [7] OCCUR PROP1665078 12/31/2006 12/31/2007 EACH OCCURRENCE FIRE DAMAGE (Any one fre) MED EXP (Airy one person) PERSONAL & ADV INJURY GENERAL AGGREGATE I'L AGO LIMIT APPLIES PER "[POLICY r>ROJECTn toe PROOUCTS-COMP/DP AGO 0,OUU,IHJU 100.000 B AUTOMOBILE LIABILITY *. ANY AUTO AU. OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS CA6691454 12/31/2006 12/31/2007 COMBINED SINGLE LIMIT 1.000.000 BODILY INJURY (Per person) BODILY INJURY (Per iccfcfent) •ROPERTY DAMAGE GARAGE LIABILITY n AUTO ONLY EA ACCIDENT OTHER THANAUTO ONLY EAACC* ACCi XCESS LIABILITY TjOCCUR [J CLAIMS MADE GBX26917 12/31/2006 12/31/2007 EACH OCCURRENCE DEDUCTIBLE" WORKERS COMPENSATION & MPIOYERS LIABILITY /| STATUTORY LIMIT I frTHEIi BB1071086 1/1/2007 1/1/2008 EL EACH ACCIDENT EL DISEASE EA EMPLOYEE EL DISEASE POLICY LIMIT DQQj )QO .000.000!ooo.ooo professional LiabClaims Made PROP1665078^12/31/2006 12/31/2007 $5 000 000 Each Loss Limit DESCRIPTION OF OPERAJIUNS/LOCAT ONS/VEHICLES/EXCLUSIONS ADDED B INDORSEMENT/SPECIAL PROVISIONS Re All California operations of the named insured All Cafitotnia operations of named insured Wayne Perry Inc 8281 Commonwealth Avenue Buena Park CA 90621-0000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 12 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY ITS AGENTS OR REPRE SENTATiyES ID Days for Non-Payment of Premium AUTHORIZEDREPRESENTATIVE Mary Duvall 6)ACORO CORPORATION 1988 Project Address Assessors Parcel Number(s) Project # (city use only) Complete Sections 1 and 2 of the following checklist to determine your project's permanent and construction storm water best management practices requirements This form must be completed and submitted with your permit application Section 1 Permanent Storm Water BMP Requirements If any answers to Part A are answered "Yes," your project is subject to the "Priority Project Permanent Storm Water BMP Requirements," and "Standard Permanent Storm Water BMP Requirements" in Section III, "Permanent Storm Water BMP Selection Procedure" in the Storm Water Standards manual If all answers to Part A are "No," and any answers to Part B are "Yes," your project is only subject to the "Standard Permanent Storm Water BMP Requirements" If every question in Part A and B is answered "No," your project is exempt from permanent storm water requirements Part A Determine Priority Project Permanent Storm Water BMP Requirements Does the project meet the definition of one or more of the priority project categories?* 1 Detached residential development of 10 or more units 2 Attached residential development of 10 or more units 3 Commercial development greater than 100,000 square feet 4 Automotive repair shop 5 Restaurant 6 Steep hillside development greater than 5,000 square feet 7 Project discharging to receiving waters within Environmentally Sensitive Areas 2 8 Parking lots greater than or equal to 5,000 ft or with at least 15 parking spaces, and potentially exposed to urban runoff 9 Streets, roads, highways, and freeways which would create a new paved surface that is 5,000 square feet or greater Yes # No ^ V 0 • ' \s' \/ V & v/ * Refer to the definitions section in the Storm Water Standards for expanded definitions of the priority project categories Limited Exclusion Trenching and resurfacing work associated with utility projects are not considered priority projects Parking lots, buildings and other structures associated with utility projects are priority projects if one or more of the criteria in Part A is met If all answers to Part A are "No", continue to Part B Part B Determine Standard Permanent Storm Water Requirements Does the project propose 1 New impervious areas, such as rooftops, roads, parking lots, driveways, paths and sidewalks'7 2 New pervious landscape areas and irrigation systems? 3 Permanent structures within 100 feet of any natural water body? 4 Trash storage areas'? 5 Liquid or solid material loading and unloading areas? 6 Vehicle or equipment fueling, washing, or maintenance areas? 7 Require a General NPDES Permit for Storm Water Discharges Associated with Industrial Activities (Except construction)?* 8 Commercial or industrial waste handling or storage, excluding typical office or household waste? 9 Any grading or ground disturbance during construction? 10 Any new storm drams, or alteration to existing storm drains? Yes M No L/ ^ ^ J PI v/ ^ 1u V *To find out if your project is required to obtain an individual General NPDES Permit for Storm Water Discharges Associated with Industrial Activities, visit the State Water Resources Control Board web site at, www swrcb ca gov/stormwtr/mdustnal html Section 2 Construction Storm Water BMP Requirements If the answer to question 1 of Part C is answered "Yes," your project is subject to Section IV, "Construction Storm Water BMP Performance Standards," and must prepare a Storm Water Pollution Prevention Plan (SWPPP) If the answer to question 1 is "No," but the answer to any of the remaining questions is "Yes," your project is subject to Section IV, "Construction Storm Water BMP Performance Standards," and must prepare a Water Pollution Control Plan (WPCP) If every question in Part C is answered "No," your project is exempt from any construction storm water BMP requirements If any of the answers to the questions in Part C are "Yes," complete the construction site pnontization in Part D, below Part C Determine Construction Phase Storm Water Requirements Would the project meet any of these criteria during construction? 1 Is the project subject to California s statewide General NPDES Permit for Storm Water Discharges Associated With Construction Activities? 2 Does the project propose grading or soil disturbance? 3 Would storm water or urban runoff have the potential to contact any portion of the construction area, including washing and staging areas? 4 Would the project use any construction materials that could negatively affect water quality if discharged from the site (such as, paints, solvents, concrete, and stucco)? Yes \A 0 • No V/ Part D Determine Construction Site Priority In accordance with the Municipal Permit, each construction site with construction storm water BMP requirements must be designated with a priority high, medium or low This pnontization must be completed with this form, noted on the plans, and included in the SWPPP or WPCP Indicate the project's priority in one of the check boxes using the criteria below, and existing and surrounding conditions of the project, the type of activities necessary to complete the construction and any other extenuating circumstances that may pose a threat to water quality The City reserves the right to adjust the priority of the projects both before and during construction [Note The construction priority does NOT change construction BMP requirements that apply to projects, all construction BMP requirements must be identified on a case-by-case basis The construction priority does affect the frequency of inspections that will be conducted by City staff See Section IV 1 for more details on construction BMP requirements ] ) High Priority 1) Projects where the site is 50 acres or more and grading will occur during the rainy season 2) Projects 1 acre or more 3) Projects 1 acre or more within or directly adjacent to or discharging directly to a coastal lagoon or other receiving water within an environmentally sensitive area 4) Projects, active or inactive, adjacent or tributary to sensitive water bodies Medium Priority 5) Capital Improvement Projects where grading occurs, however a Storm Water Pollution Prevention Plan (SWPPP) is not required under the State General Construction Permit (i e , water and sewer replacement projects, intersection and street re-alignments, widening, comfort stations, etc) 6) Permit projects in the public right-of-way where grading occurs, such as installation of sidewalk, substantial retaining walls, curb and gutter for an entire street frontage, etc , however SWPPPs are not required 7) Permit projects on private property where grading permits are required, however, Notice Of Intents (NOIs) and SWPPPs are not required \C) Low Priority 8) Capital Projects where minimal to no grading occurs, such as signal light and loop installations, street light installations, etc 9) Permit projects in the public right-of-way where minimal to no grading occurs, such as pedestrian ramps, driveway additions, small retaining walls, etc 10) Permit projects on private property where grading permits are not required, such as small retaining walls, single-family homes, small tenant improvements, etc Owner/Agent/Engineer Name (Please Print) Signature