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Home My Public Portal About5123 AGNES AVE_Electrical_8/5/2017OWNER -BUILDER DECLARATION I hereby affirm und er 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 C od e): Any city or county that requir es a permit to construct, alter, improve, demolish, or repair any structure, pri or to its issua nce, als o requires the applicant for the permit to file a signed statem ent that he or she is licensed pursuant to the pr ovisi ons of the Contracto rs' Sta te Lic ense Law (Chapt er 9 (comm en cing with Sec tio n 7000) of Division 3 of the Business and Prof essio ns Code ) or tha t he or she is e xempt fr om licensure and the basis for the alleged e xemption. Any 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) .): L) I, as owner of the property, or my employees with wage s as the ir sole compensation, will do (-/) all of or L) porti ons of the work, a nd the structure is not intended or offered for sal e (Section 7044, Busine ss and Pro fe ssio ns Code: Th e Contractors' State License Law does not apply to an owner of pro pe rty who, through employees' or personal effort, builds or improv es 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 hav e the burden of proving that it was not built or improv ed fo r the purpos e of sa le.). o I, as o wne r of the prope rty, am ex clusive ly co ntra cting with licen sed Contractors to construct the pro je ct (Se ctio n 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). 0: I am exe mdt fro m licensure unde r the Contra cto rs ' State License La w fo r the follo wing rea son: By my signa ture below I ac knowledge that, except for my personal re sidence in which? 1 must hav e reside d fo r at le ast one ye ar priori to co mple tio n of the improv ements cove red by this pe rmit, I cennot legally sell a struc ture that I have built as an owner -builder if it has no t bee n constructed in its entirety by lice ns ed c ontractors. 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://wUw.leginfo. ca.00v/calaw.html. Da te: Signature of Property O wner or Authorize d A ge nt LICENSED CONTRACTOR'S DECLARATI ON I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with S ectio n 7000) of Division 3 of the Business and Professions Code, a nd my license is in full force and effect. License Class Lic ense No. ?) / & D at e >/ L / i contr actor Signatur e L' WORKERS' CO MPENS ATION DECLARATION - WARNING: FAILURE TO SECURE WORKERS' CO MPENSATION -CO VERA GE IS UNL AWFUL, AND SHALL SUBJECT AN E MPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITI ON TO THE C OST OF COMPENSATION, D AMAGES AS PRO VIDED F OR IN SECTION 3706 OF THE LAB OR CODE, INTEREST, AND ATTORNEYS FEES. I h er eby affirm under pen alty of perjury one of the following declar ations: 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. I ha ve and will mai ntain w orkers' comp ens ati on insurance, as required by Secti on 3700 of the Labor Code, for the performance of the work for which this permit is issued. My wo rkers' 9bmpynsatiop inu}nce : rrier and policy n tubes ar9: n / 77 7 Expiration Date Ca(rier v� drr Policy Number Na me of Agent Phone Number I c ertify tha t, in the performance of th e work f or which thi s permit is issued, I shall not employ any person in any manner so as to be co me subject to the workers' compensation laws of Californ ia , and agree that, if I should become subject to the workers' compensa tion provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions Signature of Applicant 2/g /1 7 Date LO BBY IST O RDINANCE CERTIFICATION Co mplete this sectio n for permits in Uninco rpo rated Los An geles County o nly This is to certify that I, as permit applicant, am familiar with the requirements of tos Angeles County Code Chapter 2. 160 et seq., (relating to the Lo s Angeles County Lobbyist Ordinance) an d that all persons acting onbehalf of myself complied and will continue to comply therewith through the application process. Applicant (Print Name) A pplicant Signature Company Name Da te JOB ADD RES S LOCALITY HAZARD OUS MATERIAL DECLARATI ON Will the applic ant or future building occupant handle a h azardous m aterial or a mixture containing a hazardous material equal to or greater than the amount specified on the hazardous materials information guide? Y es ❑ 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)? Se e per mitting ch ecklist -f or guidelines. Yes ❑ N ❑ I hav e r ead th e haz ardous materials information guide and the SC AQ MD pe rmitting checklist, I understand my requirements under the Los Angeles County Code Title 2, Chapter 220' Sections 220A00 through 220 .140 concerning hazardous material reporting and for obtaining a permit from the SCAQMD . ASBESTOS N OTIFICATI ON ❑ N otificati on letter sent to AQ MD and/ or EP A ❑ I decl ar e th at notific ation of asbestos remo val is not applicable to addressed pr oj ect. DECLARATI ON REGARDING C ONSTRUCTION LENDING AGENCY I her eby affirm under p enalty of perjury that there is a C onstructi on 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 authoriz ed to act on the prop erty owner 's behalf . I have read this application and the informati on I have provided is correct. I agr ee to comply with all applicable city and county ordinan ces and state laws r elating to building construction. 1 auth orize representatives of this county to enter the above -identifi ed pr operty for i nsp ection purp os es. Signature of Property Owner or Authori zed Ag ent Date 5 (�7