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Building Permit Application July 2021BUILDING DIVISION PERMIT APPLICATION City of Cypress 5275 Orange Avenue Cypress, CA 90630 Phone (714) 229-6730 JOB ADDRESS LOT PROPOSED USE NEW OWNER MAILING ADDRESS CITY ADD ALTER REPAIR TRACT DEMOLISH SPECIAL STATE ZIP CONTRACTOR MAILING ADDRESS CITY TEL. STATE LIC. CLASS ARCHITECT OR ENGINEER STATE LIC. NO. STATE STATE LIC. NO. CITY BUS. LIC. TEL. ZIP BUILDING PERMIT FIRE ZONE ZONE GROUP TYPE CONST. DATE JOB DESCRIPTION FRONT YARD PLANNING DEPT. APPROVAL LIMITED TIME USE FROM: AREA SQ. FT. VALUATION NO. STORIES RIGHT SIDE YARD LEFT SIDE YARD ENGINEERING DEPT. APPROVAL LIMITED TIME USE TO: ROOF COVERING FENCING – LIN. FT. REAR YARD LOT SIZE PLUMBING PERMIT MECHANICAL/ HEATING PERMITSR # WATER CLOSET BATH TUB SHOWER LAVATORY SINK DISHWASHER LAUNDRY TUB CLOTHES WASHER FLOOR DRAIN FLOOR SINK MISC. MISC. MISC. 13.00 13.00 13.00 13.00 13.00 13.00 13.00 13.00 13.00 13.00 13.00 13.00 13.00 NO.ITEM AMOUNT NO.ITEM AMOUNT NO.ITEM AMOUNT WATER HEATER OUTLET OVER 5 VACUUM BREAKER HOUSE SEWER / GI CONNECT ADD. H.S. SEWER CAP PLUMBING PERMIT GAS SYSTEM (UP TO 5 OUTLET) INSTALL OR ALTER WATER SYSTEM INSTALL OR ALTER WASTE OR VENTS P-TRAP POOL DRAIN 16.00 7.00 2.00 16.00 7.00 7.00 92.00 7.00 13.00 13.00 30.00 PLUMBING TOTAL $ F.A.U. 1 - 100M OVER 100M DUCT ALT. or ADD KITCHEN BATH VENT COMM. HOOD A.C. UNIT WALL FURNACE / F.P. SMOKE / FIRE DAMPER MISC. HEATING PERMIT OUTLET OVER 5 COST EACH GAS SYSTEM (UP TO 5 OUTLET) ELECTRICALPERMIT 20.00 23.00 14.00 9.00 14.00 20.00 20.00 7.00 2.00 14.00 30.00 HEATING TOTAL $ NO.ITEM EACH FEE SERVICE 0-600V NOT OVER 200A SERVICE 600V OVER 200A SERVICE 600V OVER 400A PANEL BOARD SWIM POOL / SPA TIME CLOCK SIGNS NO. TRANS. / BALLASTS / INVERTERS TEMPORARY POWER POLES PERMIT FEE EACH METER NO.ITEM EACH FEE OUTLETS / SWITCHES / SMOKE DETECTORS LIGHTING FIXTURES RANGE - OVEN - GARBAGE DISPOSAL DISHWASHER - KITCHEN FAN CLOTHES WASHER / DRYER WATER HTR. POOL HTR. SPACE HTR. NEW RESIDENTIAL OUTLETS MOTORS OVER INC. HP MISC. / ARC FAULT PLAN CHECK ENERGY PLAN CHECK MECHANICA/PLUMBING PLAN CHECK ELECTRICAL PLAN CHECK ACCELERATED FEE PC # TOTAL PLAN CHECK DUE $ FEE SUMMARY 2.00 1.00 2.00 7.00 7.00 7.00 7.00 .07 Sq/Ft 7.00 16.00 30.00 23.00 1 to 20 OVER 20 0 - 1 1 - 10 10 - 50 39.00 77.00 153.00 23.00 61.00 7.00 30.00 30.00 30.00 TOTAL FEE $ REVOLVING FUND BP (58.00) BP CNSVTN PHP PHP EP TOTAL AMOUNT DUE $ I have read the front and back of this application and state that the information is correct and agree to comply with all City ordinances and State Laws regulating the work for which this permit is intended. I certify that I am properly registered and/or licensed as required by City of Cypress and State of California or that I am the legal owner of the above described property. Signature of Permitee:Building Dept. PERMIT NUMBER B-1, ver. 07-22, Building Permit Application - THIS RECEIPT IS VALID ONLY WHEN AUTHORIZED BY THE CITY’S FINANCE DIVISION - TEL. SB 1473 BUILDING ADMIN BUILDING FEE SB 1374 PLUMBING FEE HEATING FEE ELECTRICAL FEE LICENSED CONTRACTORS' DECLARATION:I hereby affirm that I am licensed under the provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Signature ___________________________________________________________________________________ TO CRIMINAL PENALTIESAND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000) INADDITION TO THE COST Policy No. ______________________________________________________ Lic. Class: _____________________ Lic. No. _________________________________ Exp. Date: ___________ THIS DECLARATION BECOMESAPART OF THE PERMANENT PERMIT RECORD: WARNING: FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECTAN EMPLOYER Job Address: __________________________________________________________________________________ Permit No. ____________ Issuance Date ________ I have and will maintain a certificate of consent to self-insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Carrier _____________________________________________ Policy Number ____________________________ Date: ___________ Applicant: _____________________________ Signature: _____________________________ Name of Agent _________________________________________ Phone # _______________________________ OWNER BUILDER DECLARATION:I hereby affirm that I am exempt from the Contractor's License Law for the reasons listed belowby the checkmark(s) I have placed next to the applicable item(s). (Section 7031.5, Business and Professions Code: Any city 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 is licensed pursuant to the provision of the Contractor's License law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt from licensure and the basis for the alleged exemption. Any violation of Section 7031.5 by an applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: OF COMPENSATION, DAMAGESAS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST,ANDATTORNEY'S FEES. I hereby affirm under penalty of perjury one of the following declarations: I, as owner of the property or my employees with wages as their sole compensation, will do (___) all of or (___) portions of the work, and the structure is not intended or offered for sale. (Section 7044, Business and Professions Code: The Contractor's State License Law does not apply to an owner of a property who, through employees' or personal effort, builds or improves the property, provided that the 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 it was not built or improved for the purpose of sale.) 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 provision of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. - WORKERS' COMPENSATION INSURANCE DECLARATION - I am exempt from licensure under the Contractor's State License Law for the following reason: I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civil Code). I am the property owner or authorized to act on the property owner’s behalf. I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section 7044, Business and Professions Code: The Contractor's State License law does not apply to an owner of a property who builds or improves thereon, and who contracts for the projects with a licensed Contractor pursuant to the Contractor's State License Law.) DECLARATION REGARDING CONSTRUCTION LENDING AGENCY I agree to comply with all applicable city and county ordinances and state laws relating to building construction. Lender’s Address: I authorize representatives of this city or county to enter the above-identitifed property for inspection purposes. Signature of Property Owner or Authorized Agent _______________________________________ Date __________ ______________________________________________________________________________________________ I have read this application and the information I have provided is correct. Date: ___________________ Name of Owner: _______________________________________ By my signature below, I certify to each of the following: http://www.legalinfo.ca.gov/calaw.html By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one year prior to completion of the improvements covered by this permit, I cannot legally sell a structure that I have built as an owner-builder if it has not been constructed in its entirety by licensed contractors. I understand that a copy of the applicable law, Section 7044 of the Business and Professions Code, is available upon request when this application is submitted or at the following Web site: Lender’s Name: ________________________________________________________________________________ ______________________________________________________________________________________________ T. P. P. Setbacks Soil Work Uffer Footings Grout/Steel Gr. Work UG Elect Slab Joists Pre-roof Sheath In Prog. R. Plbg. Ducts R.Elect. Conduit Framing Sewer Insulation Drywall Ext. Lath Sc. Coat T-Bar Gas Test FINALS Permit # INSPECTION RECORD _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ ________________