9802-017 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chap er 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License Lic. Class E:xp. Date
3 C-53
ate : Signature of Contractor t ,t
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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 & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with ' licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section . , B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensatio as provided for by Section 3700 of the Labor Code, for the
perform ce of the work for which this permit is issued.
have and will maintain workers' compensation insurance, as required by
eRtion 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
STATE FIM 0768 125-97
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) 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, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if�'�
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize,
uthorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
ignature (Owner/Agent) ' vl'+� Date
PERMIT# CONTROL'#
BUILDING PERMIT
DATE VALUATION LOT 807,101i% TRACT
S31.500.00 V
JOB SITE
ADDRESS
54•-4% Ri IERA
OWNER
CONTRACTOR / DESIGNER / ENGINEER
ROGER R. TALLAKSON
MIRAGE NVATER FEATURES
54440 RIVIERA
75080 ST. CHARLES .PL, fig
LA QUINTA 9 92253
PALM DESERT CA 92211
i"�6Q? S6$-Q8S2 C131,0! 571
USE OF PERMIT
NIMAGE W KCFR: Y rAT JkES
W 101.
71,111RO C Y UT T70, Pl . fi
POOL & SPA ONLY, POOL ALARNFAARRi1 R 814ALL BE INSTALLED AND
C3PF31 ,*moNA.L PRLOK'r0 ENCAPIPRE-PLA.ITFR INSPECTION
POOL ANDIOR S1 A 311,300,00 LS
ESTIAiATED COSTOF CONST.l UCl RYN
31,51)ii.1lU
PERMIT FEE SWANIARY
PLAN Cr WX K F11- 2 101-000-430-3113 $1.93,38
CO14arRUCItION VEX 101-000-418-040 $297.50
NfE HAN1CAL 1✓ -- POOH. 10.1 -M -421-M $24.00
ELECTRICAL FEE -- POOL 101-000-420-040 $45.00
PLM1EING MEE -- POOL 101-0Q0-419-000 $27,40
r.. {
SUB.`TAL CONSTRUCTION AND PLAN CHECK
VLESS PRL-PAlll FEES
$0.00
r'
TOTAL PERMIT FEES DUE NOW
$596.88
14
RECEIPT
DA
5F181.�
BY
a/�
DATE FINALED
INSPECTOR
I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
' 'BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade "
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls -
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath'
i
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping 1
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral i .
Pool Cover
Sewer Connection '
Encapsulation - /
Gas Piping
Gas Test
Appliances
Final
COMMENTS: ,-re-Ikd 50 �3.r...
�/,�,2n►s TNSiRII�
�• zit L/ D F -#e5 Dooit-/ �i4•PA4 6
Final
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
Utility Notice (Perm) .