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Home My Public Portal About5123 AGNES AVE_Building_2/6/2017_B15-10883OWNER -BUILDER DECLARATION hereby affirm under penalty of p erjury that I am ex empt fr om the Contractors' Stat e Lic ense Law for the re ason(s) indicated below by the checkmark(s) I have placed next to the applicabl e item(s) (Section 7031.5, Business and Professions Code): Any city or county that requires a permit to construct, alter, improve, de molish, or re pair any structure, pri or to its issua nce, als o requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contracto rs' Sta te License Law (Chapt er 9 (c ommenci ng with Section 7000) of Division 3 of the B usi ness and Professions Co de ) or tha t he or s he is exempt from lic ensure and the basis for the alleged e xemption. A ny violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500) .): U I, as owner of the property, or my employees with wages as their sole compensation, will do (J ) all of or U portions of th e work, a nd the structure is no t inte nded or offered for sale (Sec tion 7044, Busine ss and Professions Code: The C ontractors' State Lice nse La w does not apply to an owner of prope rty who , thro ugh e mplo ye es' or personal effort, builds or improves the property, pro vided 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 pro pe rty, am exc lusiv ely contra cting with licen sed Contractors to construc t the project (Sec tion 7044, Busine ss and Professions Code: The Contracto rs' State License La w do es 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 e xe mpt fro m licensure under the Co ntra ctors' State License Law for the following reaso n: By my signature below I acknowle dge that, except for my personal residence in which I must ha ve re sided fo r at lea st one year prior to completion! of the improv ements co vered by this pe rmit, I cannot legally sell a structure tha t I have built as an o wne r -builder f it has not bee n co nstructe d in its entirety by licensed co ntractors. I un derstand 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 : htto://www.leoinfo. ca. gov/calaw.html. Date : Signa ture of Property Owne r or A utho rized Age nt LICENSED CONTRACTOR'S DECLAR ATION I h ereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Di vision 3 of the Business and Professions Code, and my license is in full force and effect . CJ -License Class Lic ens e N o. vi J m' 1 D at e `76/77 C ontract or Sig natur e !.J WORKERS' C OMPENS ATION DECLARATION WARNING: F AILU RE TO SECURE WORKERS' COMPENSATION COVERA GE . IS UNLAWFUL, AND SHALL SUBJE CT AN E MPL OYER TO CRIMINAL PEN ALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUS AND DOLLARS ($100,000), IN ADDITION TO THE COST OF C OMPENSATION, D AMAGES AS PR OVIDED F OR IN SE CTION 3706 OF THE LABOR CODE; INTEREST, AND ATT ORNEY'S FEES. I h er eby affirm und er penalty of perjury one of th e following d ecl arati ons: I h ave and will maintain a certificate of consent to self - insur e 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 . X I ha ve and will maintain w orkers' c omp ens ati on in surance, as required by S ection 3700 of th e Labor Code, for the performance of th e work f or which this permit is issued. My wor er`s' comp ation insu carrier a d policy number are: arrier /Polic Number Expira'on Da e Name of Agent Phone Number I certify tha t, in the performanc e of the work for which this permit is issued, I shall not employ any p erson in any manner so as to be come subject to the workers' compensation laws of Califo rnia , a nd agree that, if I should become subject to the wo rkers' compensa tion provisions of Section 3700 of the Labor Code, I shall fo rthwith comply with those provisions %gym Signature of Applicant Date LO BBY IST O RDINA NCE CERTIFICATION Co mplete this se ctio n fo r permits in Un incorporated Los An geles County only This is to certify that I, as permit applicant, am familiar with the require ments of Los Angeles County Code Chapter 2.160 et seq., (rela ting to the Los Angeles County Lobbyist O rdina nce) and that all persons acting on behalf of myself complied and will con tinue to comply therewith though the application process. Applicant (Print Name) Applica nt Signature Compan y Name Date J OB ADDRESS. LOCALITY' HAZ ARDOUS MATERI AL DECLARATI ON Will th e appli cant or f uture building occupant handle a hazardous m aterial or a mixture containing a hazardous mat erial equal to or gr eater than the amount specified on the hazardous materials information guide? Yes ❑ No 0 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)? See permitting checklist f or guidelines. Yes 0 N o 0 - r I have r ead th e haz ardous materials information guide and the SC AQ MD permitting checklist , I understand my requirements under the Los Angeles County Code Ttle 2, Chapter 220 ' Sections 220.100 through 220.140 concerning hazardous material reporting and for obtaining a permit from the SCAQMD . ASBESTOS NOTIFICATION 0 Notification letter sent to AQ MD and/ or EPA ❑ I decl ar e that notification of asbestos removal is not applicable to addr essed project. DECLAR ATION REG ARDING C ONSTRUCTION LENDING AGENCY I h er eby 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). Lend ers Name Lender's Address By my signature b elow, I certify to leach of the following: I am the property owner or authorized to act on the prop erty own er's behalf. I have read this appli cati on and the information I h ave pro vided is correct. I agree to c omply with all applicable city and county ordina nce s and state laws r elating to building construction . I a uthoriz e r epresentatives of this county to enter the abov e -identifi ed prop erty for inspecti on purposes. Signatur e of Property Ow ner or Auth ori zed Ag ent SQte )-76lf7