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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 CONTRACTOR LEFT LOT TRACT MAILING ADDRESS SIDE YARD PROPOSED USE CITY STATE ZIP NEW ADD ALTER REPAIR DEMOLISH SPECIAL TEL. STATE LIC. NO. OWNER TEL. STATE LIC. CLASS CITY BUS. LIC. MAILING ADDRESS ARCHITECT OR ENGINEER GAS SYSTEM 7.00 UP TO 5 OUTLET CITY STATE ZIP STATE LIC. NO. TEL. I BUILDING PERMIT I FIRE ZONE GROUP TYPE CONST. DATE FRONT YARD RIGHT LEFT REAR YARD OVER 100M SIDE YARD SIDE YARD NO. ITEM AMOUNT ZONE JOB DESCRIPTION PLANNING 13.00 ENGINEERING LOT DEPT. APPROVAL BATH TUB DEPT. APPROVAL SIZE LIMITED TIME GAS SYSTEM 7.00 UP TO 5 OUTLET LIMITED TIME 13.00 USE FROM: MISC. USE TO: LAVATORY AREA NO. ROOF FENCING - SQ. FT. STORIES COVERING LIN. FT. VALUATION DISHWASHER 13.00 SR # I PLUMBING PERMIT NO. ITEM OVER 100M AMOUNT DUCT ALT. or ADD NO. ITEM AMOUNT WATER CLOSET 13.00 COMM. HOOD 14.00 WATER HEATER 16.00 BATH TUB 13.00 20.00 GAS SYSTEM UP TO 50 TLET GAS SYSTEM 7.00 UP TO 5 OUTLET SHOWER 13.00 SMOKE / FIRE DAMPER 14.00 MISC. OUTLET OVER 5 2.00 LAVATORY 13.00 HEATING TOTAL $ 77.00 VACUUM BREAKER 16.00 SINK 13.00 SERVICE 600V OVER 400A INSTALL OR ALTER 7.00 WATER SYSTEM DISHWASHER 13.00 INSTALL OR ALTER 7.00 WASTE OR VENT LAUNDRY TUB 13.00 7.00 HOUSE SEWER / GI 92.00 CLOTHES WASHER 13.00 CLOTHES WASHER / DRYER 7.00 CONNECTADD. H.S. 7.00 FLOOR DRAIN 13.00 61.00 WATER HTR. POOL HTR. SPACE HTR. P -TRAP 13.00 POOL DRAIN FLOOR SINK 13.00 TIME CLOCK 7.00 SEWER CAP 13.00 MISC. 13.00 SIGNS I NO. TRANS. / BALLASTS / INVERTERS 30.00 MISC. 13.00 7.00 PLUMBING PERMIT 30.00 MISC. 13.00 1 - 10 PLUMBING TOTAL $ ELECTRICAL PERMIT 10-50 I MECHANICAL / HEATING PERMIT I NO. ITEM AMOUNT F.A.U. 1 - 100M 20.00 OVER 100M 23.00 DUCT ALT. or ADD 14.00 KITCHEN BATH VENT 9.00 COMM. HOOD 14.00 A.C. UNIT 20.00 WALL FURNACE / F.P. 20.00 GAS SYSTEM UP TO 50 TLET 7 00 OUTLET OVER 5 COST EACH 2 00 SMOKE / FIRE DAMPER 14.00 MISC. 1.00 HEATING PERMIT 30.00 HEATING TOTAL $ ITEM NO. EACH FEE ITEM NO. EACH FEE OUTLETS / SWITCHES / 1 to 20 2.00 EACH SERVICE 0-600V NOT OVER 200A 39.00 SMOKE DETECTORS METER OVER 20 1.00 SERVICE 600V OVER 200A 77.00 LIGHTING FIXTURES 2.00 SERVICE 600V OVER 400A 153.00 RANGE - OVEN - GARBAGE DISPOSAL 7.00 PANEL BOARD 23.00 DISHWASHER - KITCHEN FAN 7.00 CLOTHES WASHER / DRYER 7.00 SWIM POOL/ SPA 61.00 WATER HTR. POOL HTR. SPACE HTR. 7.00 TIME CLOCK 7.00 NEW RESIDENTIAL OUTLETS .07 Sq/Ft SIGNS I NO. TRANS. / BALLASTS / INVERTERS 30.00 MOTORS OVER INC. HP 0 - 1 7.00 TEMPORARY POWER POLES 30.00 1 - 10 16.00 10-50 30.00 PERMIT FEE 30.00 MISC. /ARC FAULT 23.00 TOTAL FEE $ FEE SUMMARY PC # REVOLVING FUND SB 1473 PLAN CHECK BP (58.00) BUILDING ADMIN ENERGY PLAN CHECK BP BUILDING FEE MECHANICA/PLUMBING PLAN CHECK CNSVTN SB 1374 ELECTRICAL PLAN CHECK PHP PLUMBING FEE ACCELERATED FEE PHP HEATING FEE EP ELECTRICAL FEE TOTAL PLAN CHECK DUE $ 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 PERMIT NUMBER 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. - THIS RECEIPT IS VALID ONLY WHEN AUTHORIZED BY THE CITY'S FINANCE DIVISION - B-1, ver. 07-22, Building Permit Application 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. Lic. Class: Signature Lic. No Exp. Date: - WORKERS' COMPENSATION INSURANCE DECLARATION - THIS DECLARATION BECOMES A PART OF THE PERMANENT PERMIT RECORD: WARNING: FAILURE TO SECURE WORKER'S COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($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. Job Address: Permit No. Issuance Date I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 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. Policy No. ❑ 1 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: Carrier Policy Number Name of Agent Phone # ❑ 1 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. Date: Applicant: Signature: 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, as owner of the property or my employees with wages as their sole compensation, will do C_) 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, 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.) ❑ 1 am exempt from licensure under the Contractor's State License Law for the following reason Date: Name of Owner: 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: http.Nrww.legalinfo. ca.gov/calaw.hfml DECLARATION REGARDING CONSTRUCTION LENDING AGENCY 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). Lender's Name: Lender's Address By my signature below, I certify to each of the following: I am the property owner or authorized to act on the property owner's behalf. I have read this application and the information I have provided is correct. I agree to comply with all applicable city and county ordinances and state laws relating to building construction. 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 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