HomeMy Public PortalAbout5827 Alessandro Ave_Miscellaneous_11/20/2014_OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION JOB ADDRESS
I hereby affirm under penalty of perjury that I am exempt from I hereby affirm under penalty of perjury that I am licensed under I LOCALITY
the Contractors' State License Law for the reason(s) indicated provisions of Chapter 9 (commencing with Section 7000) of
below by the checkmark(s) I have placed next to the applicable Division 3 of the Business and Professions Code, and my
item(s) (Section 7031.5, Business and Professions Code): Any license is in full force and effect. HAZARDOUS MATERIAL DECLARATION
city or county that requires a permit to construct, alter, Improve,(,') e applicant or future building occupant handle a hazardous
demolish, or repair any structure, prior to its issuance, also License Class IJ License No. material or a mixture containing a hazardous material equal to or
requires the applicant for the permit to file a signed statement greater than the amount specified on the hazardous materials
that he or she is licensed pursuant to the provisions of the to 7(] Contractor Signet information guide?
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Contractors' State License Law (Chapter 9 (commencing wit
Section 7000) of Division 3 of the Business and Professions WORKERS' COMPENSA CLARATION
Code) or that he or she is exempt from licensure and the basis WARNING: FAILURE TO SECURE WORKERS' COMPENSATION
for the alleged exemption. Any violation of Section 7031.5 by COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN
any applicant for a permit subjects the applicant to a civil EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
penalty of not more than five hundred dollars ($500).): ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION
TO THE COST OF COMPENSATION DAMAGES AS PROVIDED
U I, as owner of the property, or my employees with wages as
their sole compensation, will do (J) all of or (_) portions of the
work, and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
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.).
U I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors' State License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a
licensed Contractor pursuant .to the Contractors' State License
Law).
U I am exempt from licensure under the Contractors' State
License Law for the following reason:
By my signature below I acknowledge that, except for my
personal residence in which I must have resided for at least
one year prion to completiory 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: httD://www.leainfo.ca.aov/calaw.htmi.
Date:
Signature of Property Owner or Authorized Agent
FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
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' 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.
Polic o.
I have and will maintain workers' compensation
surance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
worke cornsation insurance carder and policy n r
IM, r) Rowsz-; ?
Carder PPolicy Number Exp at n Date
Name of Agent Phone Number
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 me subject to the
workers' compensation provis' of Section 3700 of the Labor
Code, I shall fort with co with those provisions
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V LOBBYIST ORDINANCE CERTIFICATION
Complete this section for permits in
Unincorporated Los Angeles County only
This is to certify that I, as permit applicant, am familiar with the
requirements of Los Angeles County Code Chapter 2.160 at seq.,
(relating to the Los Angeles County Lobbyist Ordinance) and that
all persons acting on behalf of myself complied and will continue
to comply therewith through the application process.
Applicant (Print Name) Applicant Signature
Company Name Date
Yes ❑
No ❑
Will the intended use of the building by the applicant or future
building occupant require a permit for construction or
modification from the South Coast Air Quality Management
District (SCAQMD)7 See permitting checklist for guidelines.
Yes ❑
No ❑
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requirements
under the Los Angeles County Code Title 2, Chapter 220
Sections 220.100 through 220.140 concerning hazardous
material reporting and for obtaining a permit from the SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AOMD and/or EPA
❑ I declare that notification of asbestos removal is not
applicable to addressed project.
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 county to enter the
above -identified property for inspection purposes.
Signatu ror Athorized A
ugent
-Agate 11 r (_