03020033 CI7'YOFCUPER7'INO -.'".� �`- ..' ' � �° - �, _�;*�_�;,�
am�oinc uiv�sioN PERMIT GONTRACTOR INF9RMA170N:� �
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IIUIL�INGADDRFSS: FROLICH GORDON W AND JANET PpMI'fNO.
OW N[R'S NAML: APPUCATION SUB DATIi
FROLICH GORDON W AND JANET 02 10 2003
IONC: SANITARYNO. COMIROLNO.
ARCHITF.CT/ENGINEER: BUIL�ING P[RMff INFO
OLOG ELLCf PLUMO MECH
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°�,uoa UCF.NSCDCONTRACTOR'SDF.CLARATION JobDescri [ion
�G I hercby affrm ihm 1 em licen•eJ unJer pmvisione af Chepmr Y(rommencing P
y wiipScctinn'1IM10)nfUivisinnJnfNCBusincsxenJPrafcssinnsCnJc.enJmyliarnecie �
��� mmnmm���a�rr���. REPLACE WATER HEATER
[oYjZ I.iccnseClazs LM.M p .����
?y�,� DaM Cunuac or �tlY
���< ARCIIITLCTS DECLARATION
1 un4crs�anJ my plenx s�all bc uu�es puhlic r¢aNs
�3�`°"'° EB 2 � 2003
� LiccnseJPmlcssional
�' OWNF.R-6UILDGRU[CLARATION
��Wn 1 hcrchy aflirm ihm I om cmmpt Gnm Ihc Cnnlruqor'e Liccnnc Law fnr ihc
ap0 IiJlnwinsrcesoa(Scc�on111JI.5,�usincssan4ProfcssionsCOJc:Anyci�yurcnuniy ��I���p�^
�$� wM1ic�reyuires a pcm�ii m mnmm�,elmr.improvc,Jcmolish.or mpair any stmcmre �d\a
Fz� pnnriniuissuance,alsureyuiresiheepplican�forcuahpeemiiinfileasiS�eOsusmeni
< i�aiMislittrtscdpursuanuniMpmvisionsufNCConvacioYSLiccnxlaw�C�apmr9 Sq. FL FloorArea ,��Ation
��$ (cnmmencingwiNSeciion01AM1)n(DivisionJofihe�usinmendProfcssiuniCnlc)or
��_ Na�1¢u evemp�Nertfmm mU Jx�uu lw Ne JlcgcU eacmp�ia^.Any violaGon of
� se�uoo�o3�.seysm.oPu�.�im�.a���:�ex�um�.rvi+�N��o.��•��x�auyor �Q��er00 OccupancyType
no�mom N�n fivc�undmd dollan(55110).
❑ I.eeowrorafthepmpeny,mmyemployceawiNwegeea�Ncirmlecompen.ution,
wi1lJUNewort.andlheshvclureienntin¢ndedorottereJfnrsale(Sca]044,Buainesa —
an0 Pmfessions CoOe:'ITe Conuemoh Licensc Lew arcs nrn apply�o en owncr o( 5 0 6 - GAS TE' �� eC
pmpcny who builtls or impmw�Acmon,ond whodoe�such work himulfor Nmugh hi�
ownemployus,pmviOCENeiwc�improvemenuuenmimm�JcdoroRercAforvle.lf, SO�J — FINAL PLUMBING
�mvevee Ne huilJing ar impmvemenl is sold wiNin oro yeu of compleoon,Ne owner�
W ildcr will luve Ne WrEen o(pmving Na�he OiJ nm IuiIJ or impm�s fm puryose af
sale.).
❑ I,u mmer o(Ne pmpeny,em cxclmively conwain¢wiN littnxd conuecbn�o
consuun Ne proja�(Sec.IIN4.Bueineu m0 Rotcuiom CMe:)'The Convecbls Li- ,
cenx law docs not apply m en nwner of pmpeny who huiWe or impmvcs Ihemon,ond,
whn cnnlmcls for auch projec�a with e ronvacmr(s)littnud punuent to Nc Comracmi s
cenw Lew.
Iamexemp�unde�Sec. ,BkPCfnrNisrt�vun
lr�0l[�r>L/ F�G (./[fi�_ Da�c �
WORKER'$C MPENSATIONDECLAH�
I�crt�y e1ILm unJcr pcnepy of perjury orc of�he fullowing Ealuauov:
I luvic end will maimein e Cenificam otConunt io eelFimurt for Worker�Compcm
ution,u proviJeJ for hy Seciinn 3](MI of Ne Labor CeWe,fnr�he performance of�he
work for which Nis pc�mi�is issuN.
❑1�avc and will maimain Workch Compcnsaunn Insurancc,es myvireJ hy Scciion
3]IXI uf Ne Lebor CoOc,fnr Ne pcAmmancc of Ne wark far which Nis permi�is issucJ.
My Worker's Compcnsatinn Insunna certicr end Pulicy numMr ert:
Cortier. Poliry No.:
CERTIFICATE OF E%EMPI'ION FROM WORKEHS'
COMPENSATIONINSURANCC
(ffiissecliim neeJ nol ik mmplc�cJ if ilm permii is fnronc AunJrcJ Oollars(f Iqp
nr Icae.l
I cenify�he�in Ne perfnemanee nl�he wnrk fm which ihie permh is iseueJ,I ahell nai
cmpluyenype i ymanncr ei bcco csuh'cc�mihcWodcrs'Cnmpcnsalinn
LewsofCalifomi I ��/���> �
Applicent. ��Mil�. � eLi� d
I TO APPLICANT:IG efmr meking Nis Ccnifcam nf Rcmpiio�n.ynv shnulJ
be uhjccuo�heWurterSCompenviionprovisiumofiMlsMirCWe,youmuxi
O {Z, fo wiihenmplywii�mc�pmvisionsnrNispcemiispallMJccmcdmvnkeE.
�j O CONSTRUCfIONLENDINGAGF.NCY
[-y Ihcrc�yaffvmNaiNcrcieeconsWaionlcnJingesenrylbr�hcpcdormanccnf
(1� � ihc wnrk fur which�his permii is issuctl(Scc.JIW7,Civ.CJ
W� Q LcnJer's Nemc
�z LcnJcr'sAatlmss /�
V 0 I ccnify Nei I�eve rtaJ ihi�epplin�ion enJ su¢@ai Nc alwrc infoemaiiun i� /��
cortcci.l egree io comply wii�all city and counry uNinancu untl su¢lews relaiing m //��
0�"' builJingmnswc�ian.ma�crt�YauNomemprtunu�ivciofNiecirymcn¢rupnni�c ���
� W nMrvrmen�iuneJ propeny fnr inspcction pumoses. V �
0. (We)agrec ro save.indemmfy enJ keep harmlcss ihc City of Cupcnina a6ains�
y Iia�iliiies,judgmenu,cosuen�exprnxswhichmeyinenywayeccmcaSeinasaidCiiy �f
U 7 '��nPPLscy�uc�cUN�ERSTANDS'AND WILL COMPI.Y WITH ALL NON�POINT I5S00(�bY: DdIO � �v�
�
SO CER ULATIO 5.
Z Re-roo(s
i6�+�urc oMpplica^tlComremor Dam
HAZAF�OUSMATERIALSDISCLOSURE TypeofRoof
Will Ne applicam or fmurc Guilding mcupam smrc nr hanJlc hauNous ma¢nel
az JcfincU hy iAe Cupenino Municipal COJc,ChapNr 9.12.�nd�hc Hcal�h enE Safcry
C�de,Sec�iun 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ycs `�Nn
Will Ihc applicunt nr fmure huilJing�[cup�nl um cyuipmcnl ur Jcviccs which If a roof is installed withou[first ob[aining an inspection,I agree to remove
iil hmaNnus ai�contnminanlv o.e dcfnctl M1y lM1c Day Arca Air Quali�y Mane6�m��� all new materials for inspection.
islriCC� • "
❑YCS ��v
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1 havc maJ J�c hanNnusmamtlals mquirtmenu un@r Chap¢e fi HSofNc Califnrv
niaiicalN�Safc�yCUJc.Sa���iiu235115.255JJanJ255W.lunJcrsunONyifNc MilJing
Joes �curtenJyhauxemnem,�Ani�ismyrcspoiui�ilirymnnG aeu�wniotNc
r mre enuwnicnmusincmeiprionoissuancc�(aCcnifren¢�rtOccu . SIgI18[IIf00PAPPI1C311[ DdIO
���°�-'s��'y--��`H�°'" ��'✓`� All roof coverings to be Class "B" or better
Owncrnrewhoriicdu cnl Dmc