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Home My Public Portal About5123 AGNES AVE_Building_6/24/2018_B17-35424OWNER -BUILDER DECLARATI ON hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the reason(s) indicated below by the checkmark(s) I have placed next to the applicable item(s) (Section 7031 .5, Business and Professions Code): Any city or co unty that requires a permit to construct, alter, improve, de molish, or repair any structure, prior to its issua nce, also requires the applicant for the permit to file a signed statem ent that he or she is licensed pursuant to the pro visions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Co de ) or that he or she is exempt from licensure and th e basis fo r the alleged exemption. Any violation of Section 7031.5 by any a pplica nt for a pe rmit subjects the applic ant to a ci vil penalty of not more than fiv e hun dred dollars ($500) .): (o I, as owner of the property, or my employees with wag es as the ir so le co mpen satio n, will do el) all of or (_) portions of the work, and the structure is not intended or offered for s ale (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 improv ements are not intended or offered for sale. If, however, the building or impro veme nt is sold within one year of completion, the Owne r - Builder will ha ve the bu rde n of proving that it was not built or improved for the purpose of sale.). (_) I, as owner of the property, am exclusively contra cting with licensed Contractors to construct the project (Section 7044, Business a nd Profe ssions Code: The Contractors' State License Law does not apply to an owne r of property who builds or impro ve s thereon, and who contracts for the proje cts with a license d Co ntracto r pursuant. to the Contracto rs' Sta te License Law). (_): I am exemlit from licens ure under the Co ntra ctors' Sta te 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 prior to complefioryl 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 lic ensed contractors. I understand that a copy of the applicable. la w, Section 7044 of the Business and Professio ns Code, is ava ilable upon request when this a pplication is submitted or at the fo llo wing We b site: http://wwwJe ginfo .ca .gov/calaw.html. Date: Signature of Property Owner or A uthorized Agent LICENSED C ONTRACTOR'S DECLARATION I h ereby affirm under penalty of perjury that I am licensed under provisions of Ch apter 9 (comm encing with S ection 7000) of Di vision 3 of the Business and Professions C ode, and my license is in full force and effect. License Class (41-17License No. 62 O D ate 1,-Vb` / ntr act or Sign atur e YtW lib. }1L+ - WORKERS' CO MPENS ATION DECL ARATION WARNING: F AILURE TO SECURE WORKERS' CO MPENS ATION C OVERAGE IS UNL AWFUL, AND SH ALL SUBJECT AN E MPLO YER TO C RIMINAL PEN ALTIES AND CI VIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATI ON, D AMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABO R CODE, INTEREST, AND ATTORNEY'S FEES . 1 h ereby affirm und er p en alty of perjury one of the following d eclarations: I have and will maintain a certificate of conse nt to self - insure for workers' compensation, issued by the Direct or of Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issu ed. Policy N o. I have and will m aintain w ork er s' c ompens ati on insurance, as required by S ecti on 3700 of the Labor Cod e, f or the performance of the work for which this p ermit is issued . My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone Number I certify that, in the performan ce of the work for which thi s 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 provisions of Section 3700 of the Labor Code, I shall forthwiW comply with those provisions LOBBYIST O RDINANCE CERTIFICATION Complete this section fo r permits in . Unincorporated Los Angeles County only This is to certify tha t I, as pe rmit applicant, am familiar with the requirements of Los A ngeles County Code Chapter 2.160 et seq., (relating to the Los Angeles County Lobbyist Ordinance) and that all persons acting on be ha lf of myself complied and will. continue to co mply therewith through the application process. Applicant (Prin t Name) Applicant Sign ature . JOB ADDRESS LOCALITY HAZARD OUS MATERIAL DECLARATION Will the applicant or f uture building oc cup ant h andle a h azardo us material or a mixture containing a hazardous m aterial equ al to or greater than the amount specified on the hazardous materials i nformati on guide? Ye s ❑ No Will the intended use of the building by the applicant or future building occupant require a permit for construction or m odification from the South Coast Air Quality Management Distri ct (SCAQMD)? See permitting checklist for guidelines . Yes 0 Ns) 0 1 -have re ad the hazardous materials inf ormation guide and th e SC AQ MD , permitting checklist, I understand my req uirements under the Los Angeles County Code Title 2, Chapter 220 ' Se ctio ns 220.100 through 220 .140 concerning hazardous m at erial reporting and for obtaining a permit from the SCAQMD . ASBEST OS NOTIFICATION ❑ Notification letter sent to AQMD and/or EPA ❑ I declare that notification of asbestos removal is not applicable to addressed project. DECLARATI ON REGARDING CONSTRUCTION LENDIN G 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 Addr ess By my signature below, I c ertify to, ea ch of the following: 1 am the pr operty own er or authorized to act on the property owner's behalf. I ha ve re ad this applic ation and th e inform ation I h ave provided is c orrect. I agree to comply with all applicable city and county ordinances and state laws r elating to building construction. I authoriz e representatives of this county to enter the above -identified prop erty for inspection purpos es. "++. Signatur e rope Owner or Authorized Agent Date Com pany Name Date