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Home My Public Portal About5123 AGNES AVE_Grading_7/8/2019_GR 0508 1602080001OWNER -BUILDER DECLARA TION I hereby affirm under penalty of perjury that I am exempt from the Contra cto rs' State Lice nse La w for the reason(s) indicated belo w by the che ckmark(s) I hav e placed ne xt to the a pplicable ite m(s) (Section 7031.5, Busin ess and Professions Code): Any city or county tha t requires a permit to construct, alte r, impro ve , demolish, or repair a ny structure, prior to its issuance , also require s the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Se ctio n 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt from licen sure and the basis fo r the allege d exe mption. Any vio la tio n of Sectio n 7031.5 by a ny applicant fo r a permit su bje cts the applic ant 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 (V) all of or L) portions of the work, and the structure is not intended or offered for sale (Sec tion 7044, Business a nd Profe ssio ns Code: The Co ntractors' Sta te License Law does not apply to an owner of property who, through employe es' or persona l e ffort, builds or improves the prope rty, provided that the improvements are not intended or o ffe re d for sa le . If, howev er, the building or improvement is sold within one year of comple tion , the Owner - Builder will have the burden of proving that it was not built or improved for the purpose of sale. ). L) I, as owner of the pro pe rty, am e xclusively co ntra cting with lic ens ed Co ntra cto rs to construct the proje ct (Section 7044, Busine ss and Profess ions Co de : The Contractors' State License Law do es no t apply to an owner of pro perty who builds or improves the reo n, and who co ntra cts fo r the pro jec ts with a licensed Contractor pursuant. to the Contractors' State License Law). U 1 am exemplt fro m licensure under the Contractors' State Lice nse La w 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 o ne year prior] to c omple tion' of the improve ments covered by this permit, I cann ot legally sell a s tructure tha t I hav e built as an o wner -builder fit has not bee n constructed in its entirety by lic ensed contra cto rs. I u nderstand that a copy of the a pplicable 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://www. le ginfo.ca. gov/calaw. html. Da te: Signa ture of Property O wner or Autho rize d Age nt LICENSED CONTRA CTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Se ction 7000) of Division 3 of the Busine ss and Professions Code, and my license is in full force and effect. Lice nse Clas s (J License No. Rate 6 3 °-r//C6tractor Signature WORKER S' COMPENSATI ON DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENS ATI ON COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CI VIL FINES UP TO O NE HUND RED T HO USAND DOLLA RS ($100,000), IN ADDITION TO THE COST OF COM PENSATION, D AMAGES AS PR OVIDED FOR IN SECTION 3706 OF THE LABOR C ODE, INTEREST, AND A TTORNEYS FEES. I hereby aff irm under pena lty of perjury one of the foll owing declarations: I hav e and will maintain a c ertificate of c onsent to self - insure for wo rkers' compensation, issu ed by the Dire ct or of Industrial Re latio ns as prov ided for by S ection 3700 of the La bo r Co de , fo r the pe rforma nc e of the work f or whi ch this permit is iss ued. Po lic y No. I have and will maintain workers' compensation irisufance, as required by Section 3700 of the Lab or Cod e, for the performance off w for which this permit is issued. My workers' compensatio m d policy tuber are Th,�7t,reW m Idi are:" , its T Carrie r Policy Numb er Expirati on Date Name of A gent Phone Number I certify that, in the performance of the work for which this permit is issued, I shall no t employ any pers on in any manner so as to be come subject to the worker s' comp ensati on laws of California, and agree that, if I should becom e subj ect to th e workers' compensation provisions of Se ction 3700 of the Labor Code, I shall forthwith co mply with those provisions Signa ture of A pplicant -� Date LOBBY IST ORDINANCE CERTIFIC ATI ON Complete this se ction f or permits in Uninc orporated Los Angeles C ounty only This is to certi fy that I, as permit applicant, am familiar with the requirements of Los Angeles County Code Chapter 2.160 et seq ., (relating to the Los Angeles County Lobbyist Ordinance) and that all persons acting on behalf of myself complied and will continu e to comply therewith through the applicati on process . Applicant (Print Name) Applicant Signature Company Name Date JOB ADDRESS LOCALITY HAZARDOUS MATERIAL DECLARATI ON Will the applicant or futur e building occ upant handl e a ha zardous material or a mixtur e c ont aining a haz ard ous material equal to or great er than th e am ount sp ecifi ed on the hazardous materials information guide? Yes ❑ N o ❑ Will the intended us e of the building by the applicant or future building occupant req uire a permit for construction or m odification from the South Coast Air Quality Management District (SCAQ MD)? See permitting checklist for guidelines . Y es ❑ No ❑ r I have read the h azard ous m at erials information guide and the SCAQMD permitting checklist, I understand my requirements und er the Los Angeles County Code Title 2, Chapter 220' S ecti ons 220.100 through 220.140 concerning hazardous material reporting and for obtaining a permit from the SC AQMD . ASBEST OS NOTIFIC ATI ON 0 Notification letter sent to A QMD a nd/or EP A ❑ I declare that notification of asbestos remov al is not applicable to addressed project . DECLARATION REGARDING CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of p erjury 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 e ach of th e following: I am the property owner or authorized to act on the pr operty own er 's behalf. I have read this application and the i nf ormati on I ha ve pr ovided is correct. I agree to c omply with all applicable city and county ordi nan ces and st at e l aws relating to building construction. I authorize repr esentatives of this county to enter the ab ove -identifi ed prop erty f or insp ecti on purp oses . Sign atur e of Pr o rty Ow ner or A hori zed Agent „Sate al—