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Home My Public Portal About5123 AGNES AVE_Plumbing_8/5/2017_P17-33602OWNE R -BUILDER DECLARATION 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 ne xt to the applicable item(s) (Se ction 7031.5, Business and Professions Code): Any city or county that requir es a permit to construct, alter, improve, de molish, or repair any str uctur e, pri or to its iss ua nce, also requires the a pplic ant for the p ermit to fil e a signed statem ent that he or she is licensed pursuant to the pr ovisi ons of th e Contracto rs' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prof essions Code ) or that he or she is exempt from licensure and th e -basis for the alleged exe mption. Any violation of Section 7031.5 by an y applica nt for a permit subjects the applicant to a civil pena lty of no t more than five hundred dollars ($500) .): U I, as owne r of the pro pe rty, or my employees with wages as their sole co mpe nsatio n, will do (V ) all of or L) portions of the work, and the structure is not inte nded or offered f or sale (Section 7044, Business and Professions Code: Th e 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 o ffered for sale . If, however, the building or improve me nt is sold within o ne year of completion, the Owner - Builder will hav e the burde n of proving that it was not built or improve d for the purpose of sa le .). U I, as owner of the property, am exclusive ly co ntra ctin g with licensed Contractors to construct the project (Section 7044, Bus ines s an d Professions Code: The Contractors' State License Law does n ot apply to an owner of property who builds or improv es thereon, an d who co ntrac ts for the projects with a license d Co ntracto r pursua nt .to the C ontractors ' State License La w). U. I am e xe mpt fro m lice ns ure unde r the Co ntrac tors' State License Law for the following reas on: - By my s igna ture below I acknowledge that, ex ce pt for my perso nal residence in which I must ha ve res ide d fo r at lea st one year prior to completion; of the improv ements co vered 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 Professions Code, is ava ilable upon request when this application is submitted or at the followin g Web site : httpJ/www.leoinfo. ca.gov/calaw.html. Date: Signature of Pro perty Owner or Authorized Agent LICENSED C ONTR ACTOR'S DECLARATION I hereby affirm und er penalty of perjury that I am licens ed und er provisions of Ch apter 9 (comm en cing with Secti on 7000) of Division 3 of the Business and Prof es sions C od e, and my license is in full force and effect. License Class %3 License No. 77 (�Dat e z/6 /Contmct or Sign ature WORKERS' COMPENSATION DECLARATION WARNING: F AILU RE TO SECU RE W ORKE RS' . C OMPE NSATION CO VERAGE IS UNL AWFUL, AND SH ALL SUBJECT AN EMPLOYER TO CRI MIN AL PEN AL TIES AND CI VIL FINES UP TO ONE HUNDRED THOUSAND D OLLARS ($100,000), IN ADDITION TO THE COST OF COMPENS ATION , D AMAGES AS PRO VIDED F OR IN SECTION 3706 OF THE LABO R C ODE, INTE REST, AND ATTORNEYS FEES . I hereby affirm under penalty of perjury one of the foll owing declarations: I hav e and will, maintain a certificate of consent to self - insur e f or work ers' c omp ensation, i ssued by the Direct or of Industri al Relations as provided for by S ection 3700 of the. L abor C od e, f or the perf ormanc e of the w ork f or which this p ermit is issued. Policy No . X I have and will maintain workers' compensation ins urance,- as required by Section 3700 of the Labor Code, for the perform ance of the work for which this permit is issued . My work rs' mpe do insur ance rri er a d olicy number are: S e- /q r .-1�7- Carder Policy Number Expiration Da e Name of Agent Phon e Numb er I certify that,in the performance of the work for which this permit is issued, I shall not employ any person in any mann er so as to become subjec t to the workers' compensati on laws of Califo rnia, a nd agree tha t, if I should b ec ome subject to the workers' compensa tion provisions of Se cti on 3700 of the Labor Code, I shall forthwith co mply with those pr ovisions Signature of Applica nt---- Date LOBBYIST O RDINA NCE CERTIFICATION Comple te this section fo r permits in Un in corpora te d Lo s Angeles Coun ty only This is to ce rtify tha t I, as pe rmit applic an t, am familiar with the re quirements oftos Angeles County Code Chapte r 2.160 et seq., (rela ting to the Los Ange les Coun ty Lobbyist Ordina nce) and that a ll person s a cting on be half of myself co mplie d and will co ntinu e to comply there with through the applica tion proces s. Applicant (Print Name) Applicant Sign ature Company Name Date JOB ADD RESS LOC ALITY HAZAR DOUS M ATERI AL DE CL ARATION Will the applicant or f uture building occupant handle a ha zardous mat erial or a mixture containing a ha zard ous m ateri al equ al to or greater than the amount specified on the hazardous materi als information guide? Yes ❑ N o ❑ Will the intended use of the building by th e applicant or future building occupant require -a permit for construction or modification from the South Coast Air Quality Manag ement District (SCAQMD)? See p ermitting checklist for guidelines. Y es ❑ N ❑ - i I h ave read th e h az ardou s m aterials informati on guide and the SC AQMD p ermitti ng ch ecklist, I und er st and my requirements under the Los Angeles County Code Titl e 2, Chapter 220' Sections 220.100 through 220.140 concerning ha zard ous material reporting and for obtaining a permit from the SCA QMD . ASBEST OS N OTIFI CATI ON ❑ Notification l ett er s ent to AQ MD and/or EP A ❑ I declare that notific ation of asb esto s remo val is not applicable to addressed project. DECI ARATI ON REG ARDING CONSTRUCTION LENDING AGENCY I hereby affirm under p enalty of perjury th atthere is a Construction lending ag en cy f or the p erf ormance of the work f or which this permit is issued (S ecti on 3097, Ci vil Code). Lender's Name L ender's Address By my signature below, I certify t oeach of th e followi ng: I am the prop erty owner or authori zed to a ct on the property owner's beh alf . I hav e read this application and the information I h ave provided is correct. I agree to comply with all applic able city a nd c ounty ordina nces and state law s rel ating to building construction. I authorize representati ves of this county to enter the ab ove -identified prop erty f or insp ecti on purp oses . Sign ature of Pr op erty Owner or Authori zed Ag ent Date 2/ //7