9903-021 (SFD)J 41
1
.ICENSED CONTRA&ORDECLARATION
rid6r Penalty of perjury that I am licensed under pir6visio,nS;0.,
pencin6 with'§ecii6n 7000) of Division 3 of the Business'and.,.
de, and.7iy License is in full force and effect,
Lic..Class Exp. Date
7
_
Signature of Col
7;'itradt r
.OWNER -BUILDER DECLARATION
I herdbiy aff irm under, penalty of perjury that I am, exempt from the dontractor's
License Law . for thelollowing reason:
1, as'owher.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!(Se . C. 7044. Business & Frcifessionals'Code).
1, 'as.. owner of-the-prop'6rty,,am exclusively contracting with licensed
co'htractors'. to-construct'06 'project' (Sec.. 704 •pusiness & PrOessionals
) . I am exempt under Section "O&RC: for this reason
Date'Signature i h u"re of Owner
_
WORKER'S COMPENSATION DECLARATION
f
hereby aftirm,;under'penalt�.,of perjury.. one :of the -following,, declarations::
41
have and will maintain a certificate of consent to self -insure fo.r workers'
a
compensation,- as provided for by Section 3700 of thelabor'C ode,,for the
performance - 'of the work for'which this permit is issued.,
l.have and will maintain workers' compensation 'insurance, as required by
Sdction,3700'of the Labor 'Code,'for 'he� er'ormancefof.the work for which this
Permit is"issued.,, My= workers' compensation insurancecarrier & policy no. are:
Carrie'r, Policy.No.
,S, RZ
14
.-'V.FUM
(This 'tion:need not be comp!&ted if the permit valuation is for $100.00 or less).
(J.-Tcehify that in the performance of the work for Which this' permit is issued,
1: shall not employ any person in, any manner so as to become subject'to the
worker s',,co'mpensation laws of California, and agree that if I should become
96bject to the wo�r'ke* rs' -corpenisaition provisions of-Sectilon'3700 of the Labor
6od�e. I'shill fio hwith,comply with those provisions
Date. , #0 �
Applicant _
Warning: Failure to secure Workers' Compensation co�;e�ag �sunlawful and
Shall- subject an'employer to criminal penalties and Civil fines . up to . 410b,060*1 in
addition 'tp'the c 034 '0-f comp'e'nsati6n, damages, as provided for in Section 3706,
of Labor Code intere6t andattorney's fees.,
IMPORTANT,, Ap'p!li*c'atiqn'is heireby made to the Director of,Building and Safety
I .[o r" �A- permit. subject, to" the conditions and 'restrictions set, forth on his
application`
A. Each person , upon'Whose'behalf.this application is made & each person at
whoserequestand for whose benefit,.work is: performed under or pursuant to
: permit any I I issuej�'as a result of this . a . pp . licaton agrees to, & shall, indemnify,
& . hold:harm less 'the City of La Quinta,:its officers, agents and employees:
2. Any permit issued as a result-of,this application becom�s�null and void if
�.:work is not commeribed,within 180 days from date of. issuance, . , of such
permit, or cessation of work for
180'days Will subject permit to cancellation.
I.cdrtify thatJ1 have read this application and state that the above information i
correct:-, l.agree to'comply with all City, and State laws relatirig to the building
construction, and, hereby authorize representatives of this City to enter upon
theabove mentioned p'roperty.f*or inspection purposes.
Signature (Owner/Age, _Date - ZZ•
PERMIT"I'DOULDINGITERMIT
DATE JVALUATION-' LOT TRACT
$2221121.16 2.37
JOB SITE` I
1APN.
ADDRESS V1141 ' MONUSSE
6434M-009
OWNER
CONTRACTOR DESIGNER / ENGINEER-.",,
.WCHPLE'Ll BERGIN CQN MIUCTION
•
•'Jaefide-1 CONMI.WifilON
72-929,S1.00NARD WAY
t2-9-29 SKYWARD )WAY
RALM DESFRT CA 94260
PALM DESERT 92260
)S CBLff 4�
) 6MOSS '77
USE OF PERMIT
SFIWILPI PIA 44-1-Y ULM
VD, V17,1MV DOM NOT MCLUDE BLOCK WALL OR Pod
7RAM' CGN31RV1C'r,1CrA4 3j7624100.6-17
If lir, RCVW ATIO IiZ,00 Sr
GAkUk0VJ0.WP0R:r Sr
WMIVIATE 0 CONT OF CONN` CTION
i i4.F.CF, SUMMARNI
C0N&rR.WY10N'P`Eh— 101-000-419-000 SJ,070,0)
'PT 1-1 r- C
X
,MNC3 fEE 101 -MO -43 118 W,
lyffWrUNIC AL IF M-33 1.01 -WO -4'21J000 sss.56
ELE01TUCIV, ITVF. LFII -00 . 1210-000 $246,37
INFRASfrUGFUl-W FE -13 225-000-443-3Q $4M2.411
N?,T IN P1iRU(74 PLACFs &305,31
N -7V C
SIP XK11�4TR(X,71101N ANI -1 VLAN CHECX,
LUS PRE -PAID FEES
-"TZ50100
T()IFAL i"P, R N1 IT 'PC C.IS 0 U C NOW
1S71536.07
RECEIPT
DATE
BY/T
D ATE FINALED
INSPECTOR
INSPECTION RECORD
";PERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
�xs'04
Underground Ducts
s & Footings
i
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
;,5`
Compressor
Insulation
b —
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
= BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
' - „ r Q S
'j (�t�'
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
— Q S
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final �p
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final Z
Utility Notice (Perm)
COMMENTS:
JIF,y.r - �C,4:y,,.A+„iC.i' ,,wgJ,v:M: �,•, �-..r.+e�.-•war-^•�.✓ � �` ..�.. �•w ncrxr"iNr'---JKr'�-Jr'.....,-'A+'•orr ...�;•.,�.,ra.v.
oz/
Building
Address 47-� s v,A j to
Owner
Mailing
Address —7�
City . I Zip
Contractor
City
T4'yl 4,4 " 99a�-
P.O. BOX 1504 APPLICATION ONLY
78-495 CALLE TAMPICO
E -:55 R LA QUINTA, CALIFORNIA 92253
co .
Q C.CO .
S- --,Nva ,ess d:1 1;:�-Cjvm
State Lic.I City
& Classif. Lic. #
Designer
Address el.
Address
City Zip tate
1 LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
t.
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effec
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which repuires a
permit to construct, after, improve, demolish, or repair any structure, prior to its issuance also
repuires the applicant for such permit to file a signed statement that he is licensed pursuant, fo
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
I.: 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, Buisness 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.)
1'1 I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct 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 who contracts for
c._
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
17 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. ^ Company
n Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM,
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one'Aundred dollars ($100) valuation
or less.) •-
I certify that in the performance of thV 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:
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate o/ Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name-
Lender's
ame
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above.
mentioned property for inspection purposes.
Signature of appl
Mailing Address_
City, State, Zip_
BUILDING: TYPE'CCO�NSST�. OCCC..gGRP.
A.P. Number i.51101'2 -Y ' 1
Legal Description -c�r t`<5. <2P)
Project Description
Size t 13'. Stories
New Er"o Add ❑ Alter ❑
No. Dw.
Units
Repair ❑ Demolition ❑
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
` Front Setback foom Center Line
Rear Setback from Rear Prop. Line i
:
Side Street Setback from Center Line
Side Setback frcm Property Line
FINAL DATE NSPECTOR
Issued by: Date Permit
Validated by: �QQQ
Validation: e�+�` ®I 9
WHITE = FINANCE YELLOW = APPLICANT
PINK = BUILDING Di VISION
A
%Jq Q LA NI
Desert Sands Unified School District
47-950 Dune Palms Road
Notice:. ',La Quinta, .CA 92253 ,
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 5/10/99 APN # 643-012-009
No. 18714 Jurisdiction La Quinta
Owner NameMichael Bergin Construction Permit #
No. 47-525 Street Via Montessa Log #
✓ City La Quinta Zip 9225.3 Study, Area
Tract # 26152. Lot # 237 Square Footage 3,762
Type of Development Single Family Residence No. of Units I
Comments
6
At the present time, the Desert Sands Unified School District .does not collect fees on . garages/carports, covered
patios/walkways, residential additions.under 500 square feet, detached accessory structures or replacement mobilehomes.
It has been determined the above-named owner is exempt from paying school fees at this time due to the following
reason:
•EXEMPTION NOT APPLICABLE '
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount: of
1.93 X 3,762 or $ 7,260.66 the property listed above and tt at liuildvpg
permits and/or Certificates of Occupancy for this square footage in this proposed project may�,naw b fissue`dI
Fees Paid By .CC/1 st Bank/Michael Bergin Teleph^ e 862-9058 t T
Name on the checks
By
Dr. Doris Wilson
1...
Superintendent -
.Fee collected./exempted,by Juanita Green Payment Received $7,260.66
y
Check No. 50451
Signature
NOTICE: Pursuant of Apernbly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may pntest the fees or other payment identified
above will begin to run from the date on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or, to another public entity authorized to
collect them on the District('s)(s') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check application form to district copy for alf waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy 7 Accounting
I
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CF'y OF TN��
PUBLIC WORKS CLEARANCE LETTER
FOR
CUSTOM HOME LOTS
Dear Builder: _
Prior to issuance of a building permit, you will be required to obtain clearance from the
Public Works Department for one,, or more, of the following:
1. Verification that rough grading is complete, and the. pad elevation certifications
prepared by,a licensed surveyor, or engineer, are on file in the Public Works
Department.
Z Verification that infrastructure improvements and other required tract improvements
are complete, or sufficiently advanced to warrant building permit issuance.
3:_ Prepare an engineered grading plan that provides for on -lot storm water retention,'
+, and'have it checked and approved by the Public Works Department .
• Tract 26524 (Estancias)
• Tract 26769 (Mountain View Estates)
4. Prepare an engineered grading plan that provides for building pad grading in
accordance with the existing soils report and tract gradirg plan, and have it
checked and approved by the Public Works Department.
• Tract 28034 (South Valley Estates)
- - I
FOR INTERNAL USE BY PUBLIC WORKS DEPARTMENT
TRACT:
LOT: 3
� A
7, /zel. .11
PUBLIC WORKS AUTHORIZATION bATE
F:IPWDEPTIDOCSAFORMS\PW CLEARANCE LETTER.ss
COMMENTS:
Z
f