HomeMy WebLinkAbout1959 Palomar Oaks Way; 200; CBC2019-0144; Permit(City of
Carlsbad
Print Date: 06/04/2019
Job Address:
Permit Type:
Parcel No:
Valuation:
Occupancy Group:
# Dwelling Units:
Bedrooms:
Project Title:
1959 Palomar Oaks Way, 200
BLDG-Commercial
2130922600
$55,279.84
Commercial Permit
Work Class: Demo
Lot#:
Reference#:
Construction Type:
Bathrooms:
Orig. Plan Check #:
Plan Check#:
Description: PALOMAR OAKS WAY: 8,974 SF INTERIOR DEMO
Applicant: Owner:
Status:
Applied:
Issued:
Permit
Finaled:
Inspector:
Fina!
Inspection:
Contractor:
Permit No: CBC2019-0144
Closed -Finaled
04/01/2019
5/31/2019 6:41:39AM
WHITE CONSTRUCTION
NANCY YOUNG
CCSD LLC SP WHITE CONSTRUCTION INC
760-931-1130
BUILDING PERMIT FEE ($2000+)
BUILDING PLAN CHECK FEE (BLDG)
581473 GREEN BUILDING STATE STANDARDS FEE
STRONG MOTION-COMMERCIAL
Total Fees: $753.87
1959 Palomar Oaks Way
CARLSBAD, CA 92011
Total Payments To Date: $7S3.87
2524 Gateway Rd
Carlsbad, CA 92009-1742
760-931-1130
Balance Due:
Please take NOTICE that approval of your project includes the "Imposition" of fees, dedications, reservations, or other exactions hereafter
collectively referred to as "fees/exaction." 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 fn 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 limitation has previously otherwise expired.
$0.00
1635 Faraday Avenue, Carlsbad, CA 92008-7314 I 760-602-2700 I 760-602-8560 f I www.carlsbadca.gov
$432.58
$302.81
$3.00
$15.48
• . , _,_,. ________________________________________ _
(City of
Carlsbad
COMMERCIAL
BUILDING PERMIT
APPLICATION
B-2
Plan Check C/3( cx\'.'519 -DJ l/1./
Est. Value Oss--.,r979-'if/
PC Deposit t/,-j:>c{}-g'I
Date I../ -I ~ / q
Job Address 1959 Palomar Oaks Way Suite: 200 APN: --------------
Tenant Name: N/A -demo only CT/Project #: __________ Lot#:, ___ _
Occupancy: B-Office Construction Type: V-B Fire Sprinklers:@; no Air Conditioning® no
BRIEF DEscRIPTI0N oF woRK: Z,014 \~. hrr inttri•u, dtn10
D Addition/New: ___________ New SF and Use, ___________ New SF and Use,
____ Deck SF, Patio Cover SF (not including flatwork)
D Tenant Improvement: _____ SF, Existing Use ______ Proposed Use _____ _
_____ SF, Existing Use Proposed Use ______ _
0 Pool/Spa: ____ SF Additional Gas or Electrical Features? ___________ _
lJ Solar: ___ KW, __ Modules, ___ Mounted, Tilt: Yes/ No, RMA: Yes/ No, Panel Upgrade: Yes/ No
LJ Plumbing/Mechanical/Electrical Only: _________________________ _
~ Other: Demolition ONLY
APPLICANT (PRIMARY)
Name: White Construction
Address: 2524 Gateway Road
City: Carlsbad State: CA Zip: 92009
Phone: 760.931.1130
Email: nancy@whiteconstructioninc.com
DESIGN PROFESSIONAL
Name: FS Design
Address: 1660 Hotel Circle North #330
City: San Diego State: CA Zip: 92108
Phone: 619-296-3500
Email: marissa@fsdesigngrp.com
Architect State License: __________ _
PROPERTY OWNER
Name: Labyrinth, Inc. (CCSD, LLC)
Address: 1959 Palomar Oaks Way, Suite 300
City: Carlsbad State: CA Zip: 92009
Phone: (844) 863-0915
Email: steve@labyrinthinc.com
CONTRACTOR BUSINESS
Name: White Construction
Address: 2524 Gateway Road
City: Carlsbad State: CA Zip: _92_0_0_9 __ _
Phone: 760.931.1130
Email: nancy@whiteconstructioninc.com
State License: 1023856 Bus. License:BLNR000431-02-2017
(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/she 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/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}).
1635 Faraday Ave Carlsbad, CA 92008
B-2
Ph: 760-602-2719 Fax: 760-602-8558
Page 1 of 2
Email: Building@carlsbadca.gov
Rev. 06/18
'
( OPTION A): WORKERS'COMPENSATION DECLARATLQ!'f;
I hearby affirm under penalty of perjury one of the following dee/orations:
Cl I have and will maintain a certificate of consent to self-insure for workers' compensation provided by Section 3700 of the Labor Code, for the performance of the
work which this permit is issued.
~I have and will maintain worker's compensation, as required by Section 3700 of the Labor Code, for §t prfo<S'ance of the war~ for wriich th~percjt is issued.
My workers' compensation insurance earner and policy number are: Insurance Come_an.x Name: a e 0mpensatlOn ns. Un
Policy No. 9243036-19 Expiration Date: 01 /01 /LOLO
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 be come
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 $100,000.00, in addition the to the cost of compensation, damages as provided for in Section 3706 of the Labor Code,
interest and attorney's fees. / 1
1----□AGENT DATE: 4/1/19 ----------------------------CONTRACTOR SIGNATURE:
( OPTION B ): OWNER-BUIJ.DER DECLARATION:
I hereby affirm that I am exempt from Contractor's License Law for the following reason:
□ 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 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).
□ 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 contractor(s) licensed
pursuant to the Contractor's License Law).
□ I am exempt under Section _______ Business and Professions Code for this reason:
1. I personally plan to provide the major labor and materials for construction of the proposed property improvement. □ Yes O 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/ 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/
contractors' license number):
5. I will provide some of the work, but l have contracted (hired) the following persons to provide the work indicated (include name/ address/ phone/ type of work):
OWNER SIGNATURE: __________________ □AGENT DATE: _____ _
CONSTRUCTION LENDING AGENCY, IF ANY:
I hereby affirm that there is a construction lending agency for the performance of the work this permit is issued (Sec. 3097 (i) Civil Code).
Lender's Name: ____________________ _ Lender's Address: ____________________ _
ONLY COMPLETE THE FOLLOWING SECTION FOR NON-RESIDENTIAL BUILDING PERMITS ONLY:
Is the applicant or future building occupant required to submit a business plan, acutely hazardous materials registration form or risk management and prevention
program under Sections 25505, 25533 or 25534 of the Presley-Tanner Hazardous Substance Account Act? □ Yes ~o
Is the applicant or future building occupant required to obtain a permit from the air pollution control district or air quality management district? □ Yes~No
ls the facility to be constructed within 1,000feet of the outer boundary of a school site? □ Yes ,J'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.
APPLICANT CERTIFICATION:
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 representative 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, JUDGMENTS, 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 over 5'0' deep and demolition or construction of structures over 3 stories 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 authorized by such permit is suspended or abandoned at any time
after the work ls commenced for a period of 180 days (Section 106.4.4 Uniform Building Code).
APPLICANT SIGNATURE: ----"/_'. _____________________ DATE: _4_!1_!_1_9 ____ _
1635 Faraday Ave Carlsbad, CA 92008
B-2
Ph: 760-602-2719 Fax: 760-602-8558
Page 2 of 2
Email: Building@carlsbadca.gov
Rev. 06/18
PERMIT INSPECTION HISTORY REPORT (CBC2019-0144)
Permit Type: BLDG-Commercial Application Date: 04/0112019 Owner:
Work Class: Demo Issue Date: Subdivision:
Status: Closed -Finaled Expiration Date: Address;
IVR Number: 18010
Scheduled
Date
Actual
Start Date Inspection Type Inspection No. Inspection Status Primary Inspector
06/31/2019
June 04, 2019
BLDG-Final
Inspection
093731-2019
Checklist Item
BLDG-Building Deficiency
BLDG-Plumbing Final
BLDG-Mechanical Final
BLDG-Structural Final
BLDG-Electrical Final
Passed Paul Burnette
COMMENTS
CCSD LLC
CARLSBAD TCT#80-38
1959 Palomar Oaks Way, 200
Carlsbad, CA 92011-1316
Re Inspection
Passed
No
No
No
No
No
Complete
Complete
Page 1 of 1
Lab Number: 168089-235026
Tel: 619-474-8548 · Fax: 858-412-3305
Company:
White Construction, Inc.
2524 Gateway Rd
Carlsbad, CA 92009
Job Site: 1959 Palomar Oaks Way, Carlsbad CA-Suite 200
Lab Notes: 48 HR TAT
Date Entered:
Analyzed By:
Date Analyzed:
Customer PO / Claim#:
Contract Number:
Date Sampled
04/03/2019
04/03/2019
Tisha Melville
04/04/19
NA
Who Sampled
Louis Luick
POLARIZED LIGHT MICROSCOPY ANALYSIS REPORT -EPA-600/R-93/116 AND EPA-600/M4-82-020
Analysis Number: 168089-1
Customer Number: 01
Classification: 2X2 Calling Tile Description, White Room 1
Results: Non-Asbestos: 60% Cellulose Fibers & 10% Glass Fibers ln Gray Ceiling Tile
Analysis Number: 168089-2
Customer Number: 02
Classification: 2X2 Celling Tile Description: White Room 2
Results: Non-Asbestos: 70% Cellulose Fibers & 5% Glass Fibers in Gray Ceiling Tile
Analysis Number: 168089-3
Customer Number: 03
Classification: 2X2 Ceiling Tile Description: White Room 3
Results: Non-Asbestos: 70% Cellulose Fibers & 5% Glass Fibers in Gray Celling Tile
Analysis Number: 168089-4
Customer Number: 04
C/ass/ftcatlon: 2X2 Ceiling Tile DescrlpUon: White Room 4
Results: Non.Asbestos: 60% Cellulose Fibers & 10% Glass Fibers In Gray Ceiling TIie
· All samples tested as submitted to the lab. H.M. PITT LABS, INC. does not assume responsibility for the accuracy of the information
submitted with the samples unless done by an employee of H.M. PITT LABS. INC.
· These test results relate only to the sample(s) identified above.
· This report may not be used to claim endorsement by NVLAP or any agency of the Federal Government.
This report shall not be reproduced, except in full, without written approval of fl.M. Pitt Labs, Inc.
Samples are archived for 90 days from date of receipt and will be disposed of properly following this period.
Quantitative value ls based on PLM eves (Calibrated VJsual Estimates) with a detection limlt of <1%.
APPIIMIIBY:._~_.,.,.._rJ_s._._~_-_ Dlllt 114/14/21111
LELAND S. PITT, CIH Lee Pm
Page 1 of9
i ~ @ H.M. Pitt Labs, Inc. Lab Number: 168089-235026 ·. ' 9590 Chesapeake Dr· Ste 5 · San Diego, CA 92123 Tel: 619-474-8548 · Fax: 858-412-3305 ·-·
Company:
White Construction, Inc.
2524 Gateway Rd
Carlsbad, CA 92009
Job Site: 1959 Palomar Oaks Way, Carlsbad CA -Suite 200
Lab Notes: 48 HR TAT
Date Entered:
Analyzed By:
Data Analyzed:
Customer PO / Claim#:
Contract Number:
Date Sampled
04/03/2019
04/03/2019
Tisha Melville
04/04/19
NA
Who Sampled
Louis Luick
POLARIZED LIGHT MICROSCOPY ANALYSIS REPORT-!=PA-600/R-93/116 AND EPA-600/M4-82-020
Analysis Number: 16B0B9-5
Customer Number; 05
Classification: 2X2 Ceiling Tile Deserlptlon: White Room 5
Results: Non-Asbes1os: 70% Cellulose Fibers & 5% Glass Fibers In Gray Celling Tile
Analysis Number: 168089-6
Customer Number: 06
C/asslficallon: 2X2 Celling Tile Description: White Room 6
Results: Non-Asbestos: 70% Cellulose Fibers & 3% Glass Fibers in Gray CelUng Tile
Analysis Number: 1680811-7
Customer Number: 07
C/ass/fk;,it/on: 2X2 Ceiling TIie Description: Whtte Room 7
Results: Non-Asbestos: 80% Cellulose Fibers In Gray Ceiling Tile
Analyslfi Number: 168089-8
Customer Number: 08
Classification: Drywall Description: White Room 1
Results; Non-Asbestos: Non-Fibrous White Drywall
· All samples tested as submitted to the lab. H.M. PITT LABS, INC. does not assume responslblllty for the accuracy of the information
submitted with the samples unless done by an employee of H.M. PITT LABS, INC.
These test results relate only to the sample(s) identified above.
This report may not be used to clcdm endorsement by NVLAP or any agency of the Federal Government.
This report shall not be reproduced, except In full, without written approval of H.M. Pitt Labs, Inc.
· Samples are archived for 90 days from date of receipt and will be disposed of property following this period.
· Quantitative value Is based on PLM eves (Calibrated Visual Estimates) with a detection limit of <1%.
APPIIIVIIBY:_d/(._,....._J'_s_c:Jt_.;...· _ 11111t1: ll4/l4/ZIII
t..el.AND S. PITT, CIH a.-Pltt
Page 2of9
(_/ffl'"' '.•.--~ H.M. Pitt Labs, Inc.
~-9590 Chesapeake Dr· Ste 5 · San Diego, CA 92123
Lab Number: 168089-235026
\., -~"~--Tel; 619-474-8548 · Fax: 858-412-3305
Company: Date Entered: 04/03/2019
White Construction, Inc. Analyzed By: Tisha Melville
2524 Gateway Rd Date Analyzed: 04/04/19
Carlsbad, CA 92009 Customer PO / Claim#: NA
Contract Number:
Job Site: 1959 Palomar Oaks Way, Carlsbad CA -Suite 200 Date Sam11led Who Sam11led
Lab Notes: 4ll HR TAT 04/03/2019 Louis Luick
POLARIZED LIGHT MICROSCOPY ANALYSIS REPORT -EPA-600/R-93/116 AND EPA-600/M4-82-020
Analysis Number: 188089-9
Customer Number: 09
Classification: Drywall ~scrlptlon: White Room 2
Results: Non-Asbestos: Non-Fibrous White Drywall
Analysis Number: 188089-1D
customer Number: 1 a
Clanlflcatlon: Drywall Description: White Room 3
Results: Non-Asbestos: Non-Fibrous White Drywall
Analysis Number: 168089-11
Customer Number: 11
Classificllt/on; Drywall IJes(;r/ptlon: White Room 4
Resu/fs: Non-Asbestos: Non-Fibrous White Drywall
Analysis Number: 189089-12
Customer Numbet: 12
Classlflcatlon: Drywall Description: White Room 5
Results: Non-Asbestos: Non-Fibrous White Drywall
· All samples tested as submitted to the lab. H.M. PITT LABS, INC. does not assume responsibility for the accuracy of the information
submitted with the samples unless done by an employee of H.M. PITT LABS, INC.
· These test results relate only to the sample(s) ldentffied above.
· This report may not be used to claim endorsement by NVLAP or any agency of the Federal Government.
· This report shall not be reproduced, except in full, without written approval of H.M. Pitt Labs, Inc.
· Samples are archived for 90 days from date of receipt and will be disposed of property following this period.
· Quantitative value is based on PLM CVES (Calibrated Visual Estimates) with a detection llmlt of <1%.
APPIIIMIIBY:_t:zf/4_,,_.._J'_s_~---
LELAND S. PITT, CIH Lee Pitt
H.M. Pitt Labs, Inc. Lab Number: 168089-235026
9590 Chesapeake Dr· Ste 5 · San Diego. CA 92123 Tel: 619-474-8548 · Fax: 858-412-3305
Company: Date Entered: 04/03/2019
White Construction, Inc. Analyzed By: Tisha Melville
2524 Gateway Rd Date Analyzed: 04/04/19
Carlsbad.CA 92009 Customer PO / Claim#: NA
Contract Number:
Job Site: 1959 Palomar Oaks Way, Carlsbad CA -Suite 200 Date Sampled Who Sam11led
Lab Notes: 48 HR TAT 04/03/2019 Louis Luick
POLARIZED LIGHT MICROSCOPY ANALYSIS REPORT-EPA-600/R-93/116 AND EPA-600/M4-82-020
Analysis Number: 168089-13
Customer Number: 13
Cla"lflcation; Drywall Description: White Room 6
Results: Non-Asbestos: Non-Fibrous White Drywall
Analysis Number: 168089-14
Customer Number: 14
Classification: Drywall Description: White Room 7
Results: Non-Asbestos: Non-Fibrous White Drywall
Analysis Number: 188089-15
Customer Number: 15
Ctassificatlon: Joint Compound Description: White Room 1
RNutts: Non-Asbestos: Non-Fibrous White Joint Compound
Analysis Number: 168089-16
Customer Number; 16
Class/treat/on: Joint Compound Description: White Room 2
Results: Non-Asbestos: Non-Fibrous White Joint Compound
· All samples tested as submitted to the lab. H.M. PITT LABS, INC. does not assume responsibility for the accuracy of the Information
submitted with the samples unless done by an employee of H.M. PITT LABS, INC.
• These test results relate only to the sample(s) identified above.
· This report may not be used to claim endorsement by NVLAP or any agency of the Federal Government.
• This report shall not be reproduced, except In full, without wrftten approval of H.M. Pitt Labs, Inc.
· Samples are archived for 90 days from date of receipt and will be disposed of properly following this period.
· Quantitative value Is based on PLM CVES (Callbrated Visual Estimates) with a detection limit of <1%.
APPRDVmBY:_d_~_-_J_s_._~--'-· _
LELAND S. PITT, ClH
Page4of9
H.M. Pitt Labs, Inc. Lab Number: 168089-235026
9590 Chesapeake Dr -Ste 5 -San Diego, CA 92123 Tel: 619-474-8548 Fax: 858-412-3305
Company: Date Entered: 04/03/2019
White Construction, Inc. Analyzed By: Tisha Melville
2524 Gateway Rd Date Analyzed: 04/04/19
Carlsbad, CA 92009 Customer PO / Claim#: NA
Contract Number:
Job Site: 1959 Palomar Oaks Way, Carlsbad CA-Suite 200 Date Sameled WhoSameled
Lab Notes: 48 HR TAT 04/03/2019 Louis Luick
POLARIZED LIGHT MICROSCOPY ANALYSIS REPORT. EPA-600/R-93/116 AND EPA-600/M4-82-020
Analysis Numt,er: 168089•17
Customer Number: 17
C/asslffcation: Joint compound Description: White Room 3
Results: Non-Asbestos: Non-Fibrous White Joint Compaund
Analysis Number: 168089-18
Customer Number: 18
C/assltlcation: Joint Compound Description: White Room 4
Results: Non-Asbestos: Non-Fibrous Whlte Joint Compound
Analysis Number: 168089-19
Customer Number: 19
Classification: Joint Compound Description: Whrte Room 5
Results: Non-Asbestos: Non-Fibrous White Joint Compound
Analysis NumbM: 168089-20
Customer Number: 20
Classification: Joint Compound Description: White Room 6
Results: Non-Asbestos: Non-Fibrous White Joint Compound
· All samples tested as submitted to the lab. H.M. PITT LABS, INC. does not assume responsibility for the accuracy of the Information
submitted with the samples unless done by an employee of H.M. PITT LABS, INC.
These test results relate only to the sample(s) ldentlfled above.
Thts report may not be used to dalm endorsement by NVLAP or any agency of the Federal Government
This report shall not be reproduced, except In full, without written approval of H.M. Pitt Labs, Inc.
samples are archived for 90 days from date of receipt and will be disposed of property following this period.
Quantitative value Is based on PLM CVES (Calibrated Visual Estimates) with a detection limit of< 1 % .
AJIIIIIIVEDBY:_d/4_,...,_J'_s._._Q( __ Datlt 14/14/2111
LELAND S. PITT, CIH LHPltt
Page 5of9
(!J':•, H.M. Pitt Labs, Inc. ~ 9590 Chesapeake Dr· Ste 5 · San Diego, CA 92123
Lab Number: 168089-235026
Tel: 619-474-8548 · Fax: 858-412-3305 -~·
Company: Date Entered: 04/03/2019
White Construction, Inc. Analyzed By: Tisha Melville
2524 Gateway Rd Data Analyzed: 04/04/19
Carlsbad,CA 92009 Customer PO / Claim#: NA
Contract Number:
Job Sita: 1959 Palomar Oaks Way, Carlsbad CA -Suite 200 Date Sampled Who Sampled
L::b Notes: 48 HR TAT 04/03/2019 Louis Luick
POLARIZED LIGHT MICROSCOPY ANALYSIS REPORT -EPA-600/R-93/116 AND EPA-600/M4-82-020
Ana/ylils Num/Jer. 168089-21
Customer Number: 21
Classification: Joint Compound Description: White Room 7
Results: Non-Asbestos: Non-Fibrous White Joint Compound
Analysis Number: 188089--22
Customer Number: 22
Classification: Cove base mastic Description: White Outside Room 3
Results: Non-Asbestos: Non-Fibrous Yellow Cove Base MastJc
Analysis Number: 168089-23
Customer Number: 23
Clessltlcatlon: Cove base mastic Description: White Room 4
Results: Non-Asbestos: Non-Fibrous Yellow Cove Base Mastic
Analysis Num/Jer. 168089-24
Customer Number: 24
Classlficatlon: Cove base mastic Description: White Outside Room 5
Results: Non•Asbestos: Non•Fibrous White Cove Base Mastic
· All samples tested as submitted to the lab. H.M. PITT LABS. INC. does not assume responsibility for the accuracy of the Information
submitted wUh the samples unless done by an employee of H.M. PITT LABS, INC.
· These test results relate only to the samp/e(s) Identified above.
· Thls report may not be used to claim endorsement by NVLAP or any agency of the Federal Government.
· This report shall not be reproduced, except rn full, without written approval of H.M. Pitt Labs, Inc.
· Samples are archived for 90 days from dale of receipt and will be disposed of prope~y following 1111s period.
Quantitative value is based on PLM CVES (Cellbrated Visual Estimates) with a detection Hmlt of <1%.
APPIIIVBIBY,,_d_~_Jl_s_._ G2rf· _..,_;___ 11818t: WU/2111
LELAND S, PITT, CIH
Paga Bo/9
H.M. Pitt Labs, Inc. Lab Number: 168089-235026
9590 Chesapeake Dr· Ste 5 · San Diego, CA 92123 Tel: 619-474-8546 · Fax: 856-412-3305
Company:
White Construction, Inc.
2524 Gateway Rd
Carlsbad, CA 92009
Job Site: 1959 Palomar Oaks Way, Carlsbad CA -Suite 200
Lab Notes: 48 HR TAT
Date Entered:
Analyzed By:
Date Analyzed:
Customer PO / Claim#:
Contract Number:
Date Sampled
04/03/2019
04/03/2019
Tisha Melville
04/04/19
NA
Who Sampled
Louis Luick
POLARIZED LIGHT MICROSCOPY ANALYSIS REPORT· EPA-600/R-93/116 AND EPA-600/M4-82-020
Analysts Number: 18808&-25
Customer Number: 25
Ctassificatlon: Cove base mastic Description: White Room 7
Results: Non-Asbestos: Non-Fibrous Yellow Cove Base Mastic
Analysis Number: 16808&-26
Customer Number: 26
C/asslficatlon: Carpet Glue Description: YeJlow Room 4
Results: Non~Asbestos: 3% Synthetic Fibers in Yellow Glue
Analysts Number: 168089-27
Customer Number: 27
Ctosstffcatton: Carpet Glue Dficrlplion: Yellow Outside Room 5
Results: Non•Asbestos: < 1% Synthetic Fibers in Yellow Glue
Analysts Number: 18808&-28
Customer Number: 28
Ctasslncation: Carpet Glue Description: Yellow Room 7
Results: Non-Asbestos: 10% Cellulose Fibers in Yellow Glue
· All samples tested as submitted to the lab. H.M. PITT LABS, INC. does not assume responslblltty for the accuracy of the information
submitted with the samples unless done by an employee of H.M. PITT LABS, INC.
• These test results relate only to the sample(s) tdenHfied above.
· This report may not be used to claim endorsement by NVLAP or any agency of the Federal Government.
· This report shall not be reproduced, except in full, without written approval of H.M. Pitt Labs, Inc.
· Samples are archived for 90 days from date of receipt and will be disposed of properly following this period.
• Quantitative varue Is based on PLM CVES {Calibrated Visual Estimates) with a detection limit of <1%.
APIIIIIVIIBY:_td¼_"""_c.-f_s_~---
LELAND S. PITT, CIH Lee Pitt
Page 7of9
H.M. Pitt Labs, Inc. Lab Number: 168089-235026
9590 Chesapeake Dr· Ste 5 · San Diego, CA 92123 Tel: 619-474-8548 · Fax: 858-412-3305
Company: Date Entered: 04/03/2019 White Construction, Inc. Analyzed By: Tisha Melville
2524 Gateway Rd Date Analyzed: 04/04/19
Carlsbad, CA 92009 Customer PO/ Claim#: NA
Contract Number:
Job Site: 1959 Palomar Oaks Way, Carlsbad CA -Suite 200 Date Sampled Who Sampled
Lab Notes: 48 HR TAT 04/03/2019 Louis Luick
POLARIZED LIGHT MICROSCOPY ANALYSIS REPORT. EPA-600/R-93/116 AND EPA-600/M4-82-020
Analysts Number: 1saoag..29
Customer Number: 29
Classification: Floor tile 12 In x 12 in Description: White Break Room
RasuHs: Non-Asbestos: Noo-Flbrous White Floor Tile
Analysis Number: 168089-30
Customer Number: 30
Class//lcat/on: Floor tile 12 In x 12 in Description: White Break Room
Results: Non-Asbestos: Non-Fibrous White Floor Tile
Analysis Number. 168089·31
Customer Number: 31
Classification: Floor tile 12 in x 12 in Description: White Break Room
Results: Non-Asbestos: Non-Fibrous White Floor TIie
Analysis Number: 168089-32
Customer Number: 32
Classlllcatlon: Mastics and Glues Description: Brown Break Room
Ruults: Non-Asbestos: 10% Cellulose Fibers in Yellow Glue
· AH samples tested as submitted to the lab. H.M. PITT LABS, INC. does not assume responsibility for the accuracy of the information
submitted with the samples unless done by an employee of H.M. PITT LABS, INC.
· These test results relate only to the sampla(s) identified above.
· This report may not be used to claim endorsement by NVLAP or any agency of the Federal Government.
· This report shall not be reproduced, except in full, without written approval of H.M. Pitt Labs, Inc.
• Samples are archived for 90 days from date of receipt and will be disposed of properly followlng this period.
• Quantitative value is based on PLM eves (Calibrated Visual Estlmates)with a detection ttmit of <1%.
APPIIINEIIBY:_d/4_· ,.,.,_JJ_s_Q(____:_,_ Dabld: 14/M/2111
LELAND S, PITT, CIH ..... Pitt
Paga 8of9
:To
\
j' ~ H.M. Pitt Labs, Inc. Lab Number: 168089-235026 ',. 1.,
·-~ /
9590 Chesapeake Dr · Ste 5 · San Diego, CA 92123 Tel: 619-474-8548 · Fax: 858-412-3305
Company: Date Entered: 04/03/2019
White Construction, Inc. Analyzed By: Tisha Melville
2524 Gateway Rd Date Analyzed: 04/04/19
Carlsbad, CA 92009 Customer PO / Claim#: NA
Contract Number:
Job Site: 1959 Palomar Oaks Way, Carlsbad CA -Suite 200 Date Sam~led Who Sam~led
Lab Notes: 43 HR TAT 04/03/2019 Louis Luick
POLARIZED LIGHT MICROSCOPY ANALYSIS REPORT -EPA-600/R-93/116 AND EPA-600/M4-82-020
Analysis Number: 168089-33
Customer Number: 33
Classfficauon: Mastics and Glues Descrfptlon: Brown Break Room
Results: Non-Asbestos: 10% Cellulose Fibers In Yellow Glue
Analysis Number: 168089-34
Customer Number: 34
Classffication: Mastics and Glues Description: Brown Break Room
Results: Non-Asbestos: 15% Cellulose Fibers In Yellow Glue
· All samples tested as submitted to the lab. H.M. F'ITT LABS, INC. does not assume responsibility for the accuracy of the infonmation
submitted with the samples unless done by an employee of H.M. F'ITT LABS, INC.
· These test results relate only to the sample(s) identJfled above.
· This repcrt may not be used to claim endorsement by NVLAP or any agency of the Federal Government.
This repcrt shall not be reproduced, except in full, without written approval of H.M. F'itt Labs, Inc.
Samples are archived for 90 days from date of receipt and will be dispcsed of proper1y following this per1od.
Quantitative value is based on PLM CVES (Calibrated Visual Estimates) with a detection limit of <1%.
APl'IIIIVEDBY:_~_~_w,.,_J_s_._~--Dat8d: Wl4/2011 IIEVIWEDBY:4/~S-~
LELAND S. PfTT, CIH Lee Pitt
Page 9 of9
~ w
H.M. Pfrr LABS, INC.
9590 Chesapeake Drive, Suite 5
San Diego, CA 92123
(619)474-8548 Fax:(858)412-3305
\\ i ttf-r~r
Asbestos Survey Chain _of Custody
i)'VO#: X,; <{ ~5
Lab ID#: I\, 1, o iG\
CUSTOMER INFORMATION 1-. --------PJ(OJECJ:lt,lfQ!W'~TlON ANALYSIS "REQUESTED
ACM Tvpe
w a:F~o'-L-1:~i=au 0
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Fax: /f., ( J~Clalm#: ! l i i1g1_Q,..:
t. oE -8~"'a>
IOt'Gc ~e£ 1-~prox Sq F~et <.!2, ·.O. I : _ ., O 5. w O ·sample # I Code Color & Location
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Received by:~. -+---lr--~-"'lf---------'I~ -z;, D~te/Tlme: Is· . -f'\t,gU[iU, L.J :, w:, Ud'f!>
2 arry
"-'\IS~-
Relinquished by: ______________ _ Received by: ________________ _
Datemme:
10 • Cauldng
20 • Aircell
30 • Block TSI
35 • Blown in Insulation
40 -Carpet Glue
50 -~Ung Tile 2x4
60. Celfing TIie 12x12
90 -Dirt/Soll
100 -DrywaH
110 • Joint Cmpd.
<"-!20 • Duct Overspray
130 • Elbow TS!
140 • Expsngion Joint
150 -Exterior Stucco
70 -Composite Drywall/JC
80 • Cove Base Mastic
160 • Exterior Texture
170 -Fireproofing
loatemme:
180 • Floor Tie 12x12
190 -Floor Tie 9x9
200 • TIie Mastic
21 O • Gasllne Wrap
220 -Gasket Materials
230 • Grout
240 • HVAC Wrap
250 • Interior Wall Plaster
260 • Interior WaU Texture
270 -Mastics & Glues
280 • Parquet Mastic
290 -Pipe Insulation
300 -Rolled Roofing
310 • Roof Penetration
320 -Roofing Paper
330 • Roofing Shingles
340 -SOAC
350 • Thin Set
360 -Transite Pipe
370 -Transite Skiing
380 -Vinyl Flooring
390 -Window Putty
400 • Plaster/Orywan
410 • Wood Putty
420 • Vapor Barrier
430 -2x2 CelNng TIie
440 • 2x1 Ceftlng TIie
460 -Concrete Wall
460 -cement Block W::in
IStandard Rush: 0 24 hours
,End of Day Rush: 0
••• Amount of Homogeneous Material
Physical Assessment
# 1 Damaged or significantly damaged TSI.
# 2 O3maged friable surfacing ACM.
# 3 Signlflcantty damaged friable surfacing ACM.
# 4 Damaged or significantly damaged friable misc ACM.
# 5 ACBM with potential for significant dsmage.
# 6 ACBM with potential for damage.
# 1 Any remaining friable ACBM or friable suspect. ACBM.
~ 1:;~·h!!~~te~~!.'!~:~~-Asbestos Survey Chain of Custody
~ San Diego, CA 92123 WO#: ".,,lJ;> l( 15"'
(619)474-8548 Fax:(858)412-3305 Lab ID#: l IP b O 6 '1
CUSTO.MER INFORMATION .. PROJ.ECT ·INFPRMATION ANAL Y~1S REQUESTED
8111 To:Lo~k, ~-t {µ.,ch~, --, . sampled 8Yf _v-7 / li ,.r.,. 4 .Jr.5~ * Cftndltion "n'Potentlal. ACM Type
Addre1111:2,f"J.J1 CJLL..Jt-, d _Loc:ation: {YS-41 . ,lu.,.,A,.,-f~l,<; Wl.t...>r' r ~ Fo Dam~na i
OJ'td,.J L-.-C-nr1 LL 1,J t/1 I ~ !. ~ ~ = i
9 Qi ~~· e a, 11 2• z..>a r 'S" v \ 1..-t 2--e:> N e t;: j J cS:, "i
Phona: 7( 0 -r,, ..... l(Jo POI. * ~ ~ ~ ~ Cl -i f
--~~ a, I CC ffl ~ • i C
Fax: ?ct:> r'f'1/ ,, 1 ( Job/Clalmt: __ ...,..i [ f Ii -~ L: i ~ ·g -~ i t ~ I
Sample# Code Color&Locatlon , ... Aopro.:SQfeet <3_. ~ -~-,8 5 in.! .if .~.!-~ ~-f a ~ f
\ \ \ • P lv L 'J..-1....,.. 1'. "I (t, Z> 6-. f,-.L Ii 11--J\ {
1'<... ~ 'i Ci"
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ReMnqulshed by: ~ -_/ Received by: • 1/ '1. }...,,_., _,,..__ Turnaround Time: 'J a O .. 1 1
Datemme: '1 -J -'j I Lf D () Date/Time: / .,-'I l 3 7 I ~ 1 S : 'i ~ Regular: 0 3 to 5 days ;-, "'-) N.X:,H
ReRnqullhed by:___________ Re<:elved by:____________ Standard Rush: 0 24 hours
Date/Time: Date/Time: End of Day Rush: 0
10-Cauking 90 • Dirt/Soll 180-Floor TIie 12x12 270 • Mastics & Glues 370 -Transite Siding -Amount of Homogeneous Material
20 • Alrcell 100-Drywall 190 • Floor Tile 9X9 280 • Parquet Mastic 380 • Vinyl Flooring PhY§lfi@I Assmment
30 • Block TSI 11 o • Joint Cmpd. 200 • Tile MasUo 290 .Pipe Insulation 390 • Window Putty # 1 Damaged or aignlflcantly damaged TSI.
35 -Blown In Insulation ,~20 • Duct Overspray 210 • Gasllne Wrap 300 • Rolled Roofing 400 • Plaster/Dl')WIIII # 2 Damaged friable IIUl'fadng ACM.
40 • Carpet Glue 130 • Elbow TSI 220 • Gasket Materials 31 o • Roof Penetration 410 • Wood Putty # 3 Signlfloantly damaged friable &Urfaoing ACM.
50 • C~Nng Ti1e 2x4 140 • Expan&lon Joint 230-Grout 320 -Rooftng Peper 420 -Vapor Barrier # 4 Damaged Of slgnlflc:ent!y damaged friable mlac ACM.
60 • CelNng TIie 12K12 150 • Exterior Stucco 240 • HVAC Wrap 330 -Rooting Shingles 430 -2x2 Celling TIie # 5 ACBM with potential for significant damage.
70 -Composlto OrywalVJC 160 -Exterior TextuNI 250 • lnter10f Waft Pia.* 340• SOAC 440 • 2x1 CeMing TIie # 6 ACBM with potenUal for damage.
80 • Cove Base Mastic 170 -Fireproofing 260 -Interior WaM Texture 350 -Thin Set 450 • Concrete Wall # 7 Any remaining frtable ACBM or friable &USpecl ACBM.
360 • Transite Pipe 460 • Cement Block Wall
\,\fl,.,, 1, ~ t< ~w--V I
H.M. f'l'l"l L~A RS, INl.:. Asbestos s.urvey Chain of Custody G) 9590 Chesapeake Drive, Suite 5
San Diego, CA 92123
(619)47 4-8548 Fax:(858)412-3305
CUSTOMER INFORMATION PROJECT INFORMATION
BIIITo:t.Q\:,k,_ lo _<{✓ioh _ Sampled Byf. f c,l-GI, 4-~~ ,ff
O"I. II .,.... -,LA ,. "'"-•7 M Cnnditon
Addrtas:P,5°')JI c,.L ..Jh 1} Location: /1 5' '9 ~~.._,'1..,.. J'~l,<; -, ~ Wft..~ It) N
G.h.r/..:.li,.J 'T C-Art.r/..,.1 I\ ?Y t/J ~ ~ q~r 'S'v t k 2 ... C> It) Ill N E
Phone:?/ t? _ 'J'Jf ., l(Je, PO#. ~ V 8 "C It) Q) c
Fax: 7(;¢ ,Cf-1/ UoblClalm #: V O> ~ ,, C. ( Ill "C E 0 c 'Sample# Code . Color & Location . -Approx SQ Feet 0 Ill ~ <.!), 0 , V)'
21 t { 0 ft) l,,; ~ ~.,.,__' z_~ Uc. P{'-.I-
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ReUnqulshed by: .<;,/ .--? Received by: ·._r -t. ~
Date/Time: 4 ,-?J..-/ 1 -I'( Pv
Relinquished by:
Date/Time:
10-Cauklng
20-A1rcen
30 • Block TSI
35 -Blown In Insulation
40 • Carpet Glue
50 • C!!ttlng Tile 2x4
60 • Celling T1le 12x12
90 • Dirt/Soil
100 • Drywan
110 -Joint Cmpd.
,~20 • Duct Overspray
130 • Elbow TSI
140 -Expansion Joint
150 • Exterloc' Stucco
70 -Composite OrywalVJC 160 -Exterior Texture
80 • Cove Base Mastic 170 -Fireproofing
Date/Time:
Received by:
DatefTime:
180 • Floor Tile 12x12
190 -Floor Tile 9x9
200 -Tile MasUc
210 • GasMne Wrap
220 • Gasket Materials
230 • Grout
240 • HVAC Wrap
250 • lnterlor Wall Plaster
260 -Interior WaN Texture
I I 'i 3 / l'I lt''I !> -
270 • Mastics & Glues 370 • Transite Siding
280 • Parquet Mastic 380 • Vlnyl Flooring
290 -Pipe Insulation 390 • Window Putty
300 • RoRed Roofing 400 • Plaster/Drywall
310 -Roof Penetration 410 • Wood Putty
320 • Roofing Paper 420 • Vapor Barrier
330 -Roofing Shingles 430 -2x2 Ceiffng Tile
340 -SOAC 440 • 2x1 Celling TIie
350 • Thin Set 450 -Concrete Wall
WO#: -:.lJ:.'{ 1c;-
Lab ID#: I Iii 'l> () i "l
ANALYSIS·REQUESTEO
'ww Potential ACM Type
'-ForD: m: oe· Cl>
E u iii ~ Ill lE ·c Ill ~ e Q) Cl> 0 Ill iii co ! ~ ~ I ~ ~ .0 O> I 'ii C g Ill C: ii C Ill .§ Q) ·c ·o u cc u,
i ..: u. l ·i j f Ill Q) :0 1 ~ 0 ~ .c e 5 Ill C: en UJ ·c: 0 ::, ~ ~ ~ 5 w LL z en I-D. D. D.
,,I._ .r< ,,<._
fX :< p(
1 ' )
l \
\. \ . \
\ (
\ l
Turnaround Time: Z, U~
Regular: 0 3 to 5 days C> r-
J~ Standard Rush: 0 24 hours
End of Day Rush: 0
------
... Amount of Homogeneous Material
Physical Assessment
# 1 Damaged or significantly damaged TS!.
# 2 Osmaged friable surfacing ACM.
# 3 Significantly damaged friable surfacing ACM.
# 4 Damaged or significantly damaged ftlable misc ACM.
# 5 ACBM With potenUal for significant damage.
# 6 ACBM with potential for damage.
# 7 Any remaining friable ACBM or friable SUSl)ect ACSM.
360 • Transite Pipe 460 • Cement Block Wall
~ H.M. PITT LA.HS, lNl:. Asbestos s .urvey Chain of Custody 9590 Chesapeake Drive, Suite 5
San Diego, CA 92123
(619)474-8548 Fax:(858)412-3305
CUSTOMER INFORMATION PRPJ,ECT INFORMATION
BIIITo:LQ\<j\t._ /ti'l.fVo-cho-"' -A/'• 8-mpled By'j -'>--'"7 I JC. 4--r~~ * Condttor,,
Address.2.1 ~ C JLL J t-i d . location: (f ~1 ~ R,J.,..,,i.,-J'~lc.. ~ w~ " IO N
Cnr1 .:.l 11~
I " r" _A.I'( t f. ,d ?Y Cf1 ~ a, Cl C/~'f fvtk 2.,,:. C, II) ~ ~
Phone: ?( t) -r, I .r l u e> PO#. ~ "' ~ 0 &, i:
Fax: 7 £. ¢ ~ Cf-r / . Job/Claim #: V Cl ~ ti C. ( al "0 0 E C
Sample# Code Color & Location ....., Aoorox Sq Feet 0 Ill ~ (!) .0 .
·~ I ,~ Lt)~h lj r-c:JQ~ f'...t."'
32-1...7 r:, I\ t'1 ""''\ R~1... ~""'-")tH fL-t-'7..
3 J I I \
~'-\ ,v y \v
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..--L Rennqulshed by: -~ Received by: ... Vr/~
Datelrrne: 'i -i -f "7 I { <10 Datemme: I /"'i t~,,., IS:~ l
Rellnqulehed by: Received by:
Date/Time: Datemme:
10-Cauking 90 -Dirt/Son 180-Floor Tile 12)(12 270 -Mastics & Glues 370 -Transite Siding
20 • AirceM 100 • Orywaft 190 -Floor Tile 9x9 280 • Parquet Mastic 380 • Vinyl Flooring
30 • Block TSI 110-Joint Cmpd. 200 -TIie Mastic 290 -Pipe Insulation 390 -Window Putty
35 -Blown in Insulation ,~20-Duct Overspray 210 • GasNne Wrap 300 -Rolled Roofing 400 -Plaster/DrywaU
40 • Carpot Glue 130 -Elbow TSI 220 -Gasket Materlals 31 O -Roof Penetration 410 -Wood Putty
50 -~ftng TIie 2x4 140 • Expansion Joint 230 • Grout 320 -Roofing Paper 420 • Vapor Barrier
60-Celling r~e 12x12 150 -Exterior Stucco 240 • HVAC Wrap 330 -Roofing Shingles 430 -2x2 Ceiling TIie
70 • Composite DrywalVJC 160 -Exterior Texture 250 -Interior Wall Plaster 340· SOAC 440 -2x1 Celling Tlle
80 -Cove Base Mastic 170 -Fireproofing 260 -Interior wan Texture 350 • Thin Set 450 • Cona-ete WaU
WO#: .;.Lo l{ 15'
Lab ID#: I ~ '£ o 'b q
ANALYSIS REQUESTED
· .,...Potential ACM Type
i:;
For Dama!!• I> E .. 0 !i= ~ t: ij'
C ro a. 8 Q .
\
~ u = ·c: ~ $ GJ g en J ro 'iii ~ ~ .,: >-J:J Cl u iii 5 ('O C iii I C C: Cl) ·c: ·o .2 i c( II) e 0 L: u. ~ .iii :0 ~ t Q) § 0 1 :3 .&l e .£i ('O en Cl) ·c: ::> ~ .c .c 5 w 0 · u.. z en ..... Q. Q. Q.
i\
l
Tum•round Time: ~'7 . R egu lar: 0 3 l'O 5 days
Standard Rush: 0 24 hours 71J-(
End of Day Rush: D
... Amount of Homogeneous Materla~I --
Physical Assessment
# 1 Damaged Of significantly damaged TSL
# 2 DEmaged friable surfacing ACM.
# 3 Significantly damaged friable surfacing ACM.
# 4 Damaged or slgnlflcantly damaged friable misc ACM.
# 5 ACBM with potential for significant damage.
# 6 ACBM with potential fOf damage.
# 7 Any remaining friable ACBM or friable BUSpeci. ACBM.
360 • Transite Pipe 460 • Cement Block w .. n
RECORD ID#
OFFICE USE ONL y SAN DIEGO REGIONAL
HAZARDOUS MATERIALS
QUESTIONNAIRE PLAN CHECK#;;=================================-,' BP DATE
, l r 0
The following questions represent t e facility's activities, NOT the specific project description.
PART I: FIRE DEPARTMENT -HAZARDOUS MATERIALS DIVISION: OCCUPANCY CLASSIFICATION: (not required for projects within the City of San
Diego): Indicate by circling the item, whether your business will use, process, or store any of the following hazardous materials. If any of the items are circled,
applicant must contact the Fire Protection Agency with jurisdiction prior to plan submittal.
Occupancy Rating: Facility's Square Footage (including proposed project):
1. Explosive or Blasting Agents 5. Organic Peroxides 9. Water Reactives
2. Compressed Gases 6. Oxidizers 10. Cryogenics
3. Flammable/Combustible Liquids 7. Pyrophorics 11. Highly Toxic or Toxic Materials
13. Corrosives
14. Other Health Hazards
15. None of These.
4. Flammable Solids 8. Unstable Reactives 12. Radioactives
PART 11: SAN DIEGO COUNTY DEPARTMENT OF ENVIRONMENTAL HEALTH -HAZARDOUS MATERIALS DIVISION (HMO): If the answer to any of the
questions is yes, applicant must contact the County of San Diego Hazardous Materials Division, 5500 Overland Avenue, Suite 110, San Diego, CA 92123.
Call (858) 505-6700 prior to the issuance of a building permit.
FEES ARE REQUIRED Project Completion Date: Expected Date of Occupancy:
1.
2.
3.
4.
5.
6.
7.
8.
YES NO (for new construction or remodeling projects)
O Er Is your business listed on the reverse side of this form? (check all that apply).
O ~ Will your business dispose of Hazardous Substances or Medical Waste in any amount?
O 1:::::1 Will your business store or handle Hazardous Substances in quantities greater than or equal to 55 gallons, 500
pounds and/or 200 cubic feet? O ~ Will your business store or handle carcinogens/reproductive toxins in any quantity?
O ~Will your business use an existing or install an underground storage tank? O t::J . Will your business store or handle Regulated Substances (CalARP)? O Er' .,:,Will your business use or install a Hazardous Waste Tank System (Title 22, Article 1 0)?
O l2r Will your business store petroleum in tanks or containers at your facility with a total facility storage capacity equal to
or reater than 1,320 allons? (California's Aboveground Petroleum Storage Act).
0 CalARP Exempt
I
Date Initials
0 CalARP Required
I
Date Initials
0 CalARP Complete
I
Date Initials
PART 111: SAN DIEGO COUNTY AIR POLLUTION CONTROL DISTRICT (APCD): Any YES* answer requires a stamp from APCD 10124 Old Grove Road, San
Diego, CA 92131 apcdcomp@sdcounty.ca.gov (858) 586-2650). [*No stamp required if Q1 Yes and Q3 Yes and Q4-Q6 No). The following questions are intended
to identify the majority of air pollution issues at the planning stage. Projects may require additional measures not identified by these questions. For comprehensive
requirements contact APCD. Residences are typically exempt, except -those with more than one building• on the property; single buildings with more than four
dwelling units; town homes; condos; mixed-commercial use; deliberate burns; residences forming part of a larger project. rExcludes garages & small outbuildings.]
YES NO
1. [::]' 0 Will the project disturb 160 square feet or more of existing building materials?
2. D ff Will any load supporting structural members be removed? Notification may be required 10 working days prior to commencing demolition.
3. D ~ (ANSWER ONLY IF QUESTION 1 or 2 IS YES) Has an asbestos survey been performed by a Certified Asbestos Consultant or Site Surveillance
Technician?
4. O O (ANSWER ONLY IF QUESTION 3 IS YES) Based on the survey results, will the project disturb any asbestos containing material? Notification
may be required 10 working days prior to commencing asbestos removal.
5. D Er Will the project or associated construction equipment emit air contaminants? See the reverse side of this form or APCD factsheet
(www.sdapcd.org/info/facts/permits.pdf} for typical equipment requiring an APCD permit.
6. O D (ANSWER ONLY IF QUESTION 5 IS YES) Will the project or associated construction equipment be located within 1,000 feet of a school
bounda
Briefly describe business activities: Briefly describe proposed project:
04 / 0 I / fq
Name of Owner or Authorized Agent Signature of Owner or Authorized Agent Date
FOR OFFICAL USE ONLY: FIRE DEPARTMENT OCCUPANCY CLASSIFICATION: ________________________________ _
BY· DATE· I I
EXEMPT OR NO FURTHER INFORMATION REQUIRED RELEASED FOR BUILDING PERMIT BUT NOT FOR OCCUPANCY RELEASED FOR OCCUPANCY
COUNTY-HMO* APCD COUNTY-HMO APCD COUNTY-HMO APCD
. A stamp rn this box only exempts businesses from completing or updating a Hazardous Materials Business Plan. Other perm1tt1ng requirements may strll apply .
HM-9171 (08/15) Countv of S::1n niPnn-n~H -l-h::i7'.!lr-rfr,11c l\ll"'l+o.-i .... 1 ... n ;,,;,...;,... ...
( City of
Carlsbad
CONSTRUCTION WASTE
MANAGEMENT PLAN
B-59
Development Services
Building Division
1635 Forodoy Avenue
760-602-2719
www.corlsbadco.gov
Many of the materials generated from your project can be recycled. You are required to list materials that will be
reused, recycled or disposed from your project. If you have questions about the recycling requirement or completing
this form, please contact Waste Management at (760) 929-9400, a certified C&D recycler, or the Carlsbad Building
Division at (760) 602-2700. Please note: Unless you are self-hauling, Waste Management or approved haulers must be
used_fo_r allrnnstruction proie_i:§ within the City_Qf Carlsbad.
PART 1 Complete and submit this form when applying for a Building Permit. Note: Permits will not be issued
without a completed Construction Waste Management Plan,
Applicant Information
Permit No. ___________ _ Project Title
Project Address 1959 Palomar Oaks Way #200
Applicant Name White Construction
Demolition @ 1959 Palomar Oaks Way #200
APN
Owner Contractor Architect Other
Last First 0 J8t 0 0
Applicant Address 2524 Gateway Road, Carlsbad, CA 92009
Phone ( 760 ) 931 .1130
Applicant Mailing Address
E-mail Address nancy@whiteconstructioninc.com
(if different than project address)
Project Type
(check all that apply):
Residential
□
Public Building □
Brief Description demolition of existing walls and finishes
Project Size suite is 8,974 sf
(square footage)
Please check the appropriate box:
Estimated Cost of Project $_$_Hi0,0_0_0_.0_0 ___ _
Industrial □
□ I plan on using WASTE MANAGEMENT roll-off bin(s) for all materials and will provide all receipts after construction.
(;2!'1 plan on self-hauling to a certified recycling facility and will provide all receipts after construction.
D This is a proposed LEED certified project and I plan on separating materials on site in conjunction with WASTE
MANAGEMENT.
Acknowledgement: I certify under penalty of perjury under the laws of the State of California that the information
provided in and with this form pertains to construction and demolition debris generated only from the project listed
in PART 1, that I have reviewed the accuracy of the information, and that the information is true and correct to the
best of my knowledge and belief.
Print Name Nancy Young Date 5/1/19
Page 1 of 4 Rev. 11112118
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PART 1 Complete, obtain ,ignature, and submit this form when applying for ;i Building Permit. Note: Permits will
{cont'd) not be issued without a completed Construction Waste Management Plan.
DEBRIS RECYCLING ESTIMATE:
.__,~1111111n,•• Permit No . Project Title
Project Address_ 1959 Palomar Oaks Way #200 --APN
Applicant Name Young, Nancy (PM -White Construction) Phone ( 760 ) 931 .1130
Lost First
--~"'""illll"•: Complete the following table with estimated waste tonnage to be generated by your project.
This is your plan for construction waste management. Changes can be made on the final recycle report.
Goal: the diversion rate shall be 65% by weights of debris.
A B C
Material Type Estimated Place a (✓) check Place a ( ✓) check next Place a (✓)check next
Waste Quantity next to items to be to items to be to items to be
(tons) reused or salvaged recycled disposed at landfill
Complete this line of the toble only if
only using WASTE MANAGEMENT
roll-off bins.
Mixed C&O Debris
Asphalt & Concrete
Brick/ Masonry/ Tile
Mixed Inert Debris
Cabinets, Doors, Fixtures,
Windows (circle all that apply)
r---
Carpet 1.0 .75 .25
Carpet Padding/ Foam --
Cardboard .25 .25 0
Ceiling Tile (acoustic) .25 .18 .07
Drywall (used, new, scrap) 1.0 .7 .3
Landscape Debris (brush, trees,
stumps, etc.) No dirt.
Unpainted Wood & Pallets
Roofing Materials
Scrao Metal .6 .5 .1
Stucco
Other:
TOTAL ---To m eet 65% Diversion Requirem ent (estimate) 3.1 tons X 0.65 = 2.0 tons u-: T oto1£,t;m,ted Wo,te /,om obo,e Minimum Required Diversion
4/1/19 Contractor/Owner Signatur~-~ ~ Date
Page 2 of 4 Rev. 11/12/18