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Home My Public Portal About5123 AGNES AVE_Mechanical_8/5/2017_M17-33601OWNER -BUILDER DECLAR ATION I 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, Busi ness and Pr ofe ssions Code): Any city or co unty that requires a permit to construct, alter, impro ve, demolish, or re pair any structure, pri or to its issua nce, als o re quire s the a pplicant for th e permit to file a sign ed st at em ent that he or s he is licensed pursuant to the provisions of the Co ntra cto rs ' Sta te License Law (Ch apt er 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt from licensure and the basis for the alleged exemptio n. A ny violation of Section 7031.5 by any applicant for a permit subjects the applicant to a ci vil penalty of not more than five hundred dollars ($500) .): L) I, as ow ner of the property, or my e mployees with w ag es as the ir so le compensa tio n, will do (✓ ) all of or L) portions of th e wo rk, 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 fo r sale. If, however, the building or improvement is sold within one year of comple tion, the Owne r - Builde r will have the burden of prov ing tha t it wa s not built or impro ve d fo r the purpo se of sa le.). L) 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 Contracto r pursua nt ito the Co ntractors' State License La w). I L) I am e xempt from licens ure unde r the Co ntractors' State Licen se La w fo r the following reason: By my signature belo w I a ckno wle dge tha t, ex cept fo r my persona l residenc e in which I must hav e resided for at least o ne ye ar priori to completion 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 Professio ns Code, is available upon reque st when this application is submitted or at the following We b s ite: http://www.leginfo.ca.gov /calaw.html. Da te: Signature of Property Owner or A uthorized A gent LICENSED CONTRACTOR'S DECLAR ATION I hereby affirm under penalty of perjury that I am lice nsed und er provisions of Chapter 9 (c ommencing with S ection 7000) of Divisi on 3 of the Busi nes s and Professions Code, and my lic ense is in full f orc e and effect. License Cl ass I License No . Dat e %'/b ` / Contractor Signature Cdr. -,--1 WOR KE RS' COMPENSATION DECLAR ATI ON WARNING: F AILURE TO SECURE W ORKERS' C OMPENSATION COVERAGE IS UNL AWFUL, AND SHALL SUBJE CT AN E MPLOYE R TO CRI MINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND D OLL ARS ($100,000), IN ADDITION TO THE COST OF CO MPENS ATI ON, D AMAGES AS PR OVIDED FO R IN SECTION 3706 OF THE LAB OR CODE, INTEREST, AND ATT ORNEY'S FEES . 210°� I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of cons ent to self - insure for workers' compensation, issued by the Director of Industrial R elations as pro vided f or by Secti on 3700 of the. Labor Code, for the perform ance of th e w ork f or which this p ermit is issued. Policy N o. X I ha ve and will maint ain workers' compensation ins urance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My `pdSers'pomp ti m�sur a c arrier g poli cy & 71 Carrier tifr/�� 1C04 Carrier Policy Numb er E xpiration D ate Name of A gent Ph one N umber I 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 b ecome subject to th e workers' compensation prov isions of Section 3700 of the Labor Code, -I shall forthwith comply with those pr ovisions Signature of A pplican t Date LOBBYIST ORDINANCE CERTIFICATION Co mplete this section for permits in Unincorpora te d Lo s Angeles Co unty only This is to certify tha t I, as pe rmit applicant, am familiar with the requirements of Los Angele s County Code Cha pte r 2. 160 et seq., (relating to the Los Angeles County Lobbyist Ordinance ) and that all pe rsons a cting on behalf of myse lf complied and will co ntin ue to comply the rewith thro ugh the applica tion process. Applicant (Print Na me ) A pplica nt Signature Company Name Date JOB ADDRESS LOCALITY HAZARDOUS M ATERI AL DECLARATION Will the applicant or future b uilding occupant h andle a hazardo us material or a mixture containing a hazard ous mat eri al equal to or gre ater than th e amount sp ecifi ed on the haz ardo us materi als information guid e? Ye s ❑ - No ❑ Will the intend ed use of the building by the applicant or future building occupant req uire a p ermit for c onstructi on or modification from the S outh C oast Air Quality Management District (S CAQMD)? Se e p ermitting checklist for guid elin es. Yes ❑ No ❑ I have read the hazardous material s information guid e and the SCAQ MD permitting checklist, I understand my requirements under -the Los Angel es County Code Title 2, Chapter 220' Sections 220 .100 through 220.140 conc eming hazard ous materi al r ep orting and f or obt aining a permit from the SCAQMD. ASBEST OS NOTIFICATION ❑ Notification letter sent to.AQ MD and/or EPA ❑ I declare that notification of asbest os rem oval is n ot applicable to addressed project . DECLARATI ON REGARDING CONSTRUCTION LENDING A GENC Y I hereby a ffirm under penalty of perjury th at th er e is a Construction lending age ncy for th e performance of th e work f or which this p ermit is issued (Section 3097, Ci vil C od e). L ender' s N am e Lender's Address By my signature below, I certify to:each of th e following: I am the prop erty owner or authorized to act on th e prop erty owner's behalf. I have read this application and the information I h ave pr ovid ed is corre ct. I agree to comply with all applicable city and county ordin ances and state laws r elating to building construction. I authorize representatives of this county to ent er the abo ve -identified pr operty for inspection purposes. Signature of Property Owner or Authorized Agent 74 Date ; 5 /17