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Home My Public Portal About___OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am ex empt from the Contractors' State License Law for the reason(s) indicated belo w by the ch eckmark(s) 1 ha ve placed ne xt to the appli cabl e item(s) (Section 7031 .5, Business and Professions Code): Any city or county that requires a permit to construct, alter, impro ve, demo lish, or re pair any struct ur e, pri or to its issuance, also requires the applicant for the permit to file a signed statement that he or s he is licensed pursuant to the provisions of the Contractors' State License Law (Ch apter 9 (commencing with Section 7000) of Division 3 of the Business and Pr ofessi ons Code) or tha t he or s he is exempt from lic ensure and the basis for the a lle ge d exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil pe nalty of not more than five hundred dollars ($500) .): L) 1, as owner of the property, or my employees with wages as their sole compens ation, will do (,/) a ll of or L) portio ns of the work, and the structure is no t intended or offered for safe (Section 7044, Business and Professions Code: The Contracto rs' State License Law does no t apply to an owner of property who, through employees' or personal effo rt, builds or improves the property, provided that the improvements are not intende d or offe red for sale. if, however, the building or improvement is sold within one ye ar of co mpletion, the Owner - Builder will have the burden of proving that it was not built or impro ved fo r the purpose of sa le.). L) 1, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Sec tion 7044, Business and Pro fes sions Co de: The Contra ctors' State License Law does not apply to an owner of property who builds or improves the reon, and who contracts for the projects with a licensed Contra for pursuant to the Contrac tors' State License Law). L ). I am exempt from licensure under the Contractors' State Lice nse La w for the following reason: By my signature belo w I a cknowledge that, except for my personal residence in which 1 must have resided for at le ast o ne year prior! to completion/ of the improvements covered by this pe rmit, I cinnot legally sell a structure that I have built as an owner -builder if it has not been constr ucted in its entirety by licensed contractors. 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 fo llowing Web site: httn://www_leginfo.ca.gov/calaw. html. Date: Signa ture of Property Owne r or A uthoriz ed Agent LICENSED CONTRACTOR'S DECLARATION I .her eby a ffirm under penalty of perjury that I am licensed under provisi ons of Ch apter 9 (commencing with Section 7000) of Di vision 3 of the Business and Professions Code, and my license is in full force and effect. Lice ns e Class Date 776/17 Contractor Sign ature Lj g License No. WORKERS' COMPENSATION DECL AR ATI ON W ARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 1S UNL AWFUL, AND SHALL SUBJE CT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUS AND DOLLA RS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS P ROVIDED FOR IN SECTION 3706 OF THE LAB OR CODE; INTEREST, AND ATTORNEY'S FEES. I hereby affirm under penalty of p erjury one of th e following declar ations: I hav e and will maintain a certificate of c onsent to self - insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Section 3700 of the. Labor Code, for th e perf ormance of the work for which this p ermit is issued. Policy No . )( I have and will maintain workers' compensati on insurance, as required by Section 3700 of the Labor Code, for the performance of the work f or which this permit is issued. My wor ers' comp ation insu c carri er a d policy number are: arrie� f WWcy Number Ex piration Date Name of A gent Phone Number _ 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 beco me subject to the workers' compensation laws of California, and agree tha t, 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 ie eet Signatu re of Applicant Date 1/7. LOBBY IST O RDINA NC E CERTIFICATION Complete this section for permits in Unincorporated Lo s Ange les Co un ty only This is to certify that 1, as permit applicant, am familiar with the require ments of " Los Angeles County Code Chapter 2.160 et seq., (re la ting to the Los Angeles County Lobbyist O rdina nce) and that all persons a cting on behalf of myself complied and will c ontinue to comply therewith through the application process. Applicant (Print Name) Applicant Signature Company Na me Date JOB ADDRESS LOCALITY HAZARD OUS MATERI AL DE CLARATI ON Will the applicant or future building occupant handle a hazardous material or a mixture containing a hazardous materi al equ al to or greater than the amount specified on the hazardous materials information guide? Yes 0 N o 0 Will the intended use of th e building by the applicant or future building occupant require a permit for c onstr uction or modification from the South Coast Air Quality Management Distri ct (SCAQMD)? See permitting ch ecklist for guidelines. Y es ❑ N.o D I have read the hazardous mat erials information guide and the SC AQ MD pernhitting checklist, I understand my requirements under the Los Ang eles C ounty Code Titl e 2, Chapter 220 ' Sections 220.100 through 220.140 c oncerning h azardous material reporting and for obtaining a permit from the SCAQMD. ASBESTOS NOTIFICATION ❑ Notification letter sent to AQMD and/or EPA ❑ I declare that notification of asbestos removal is not applicable to addressed project. DE CLARATION REG ARDING C ONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a Construction [ending agen cy for the performance of the work for which this permit is issued (S ection 3097, Ci vil Cod e). Lend er's Name Lender's Address By my signature below, I certify to each of th e followi ng: am the property owner or authorized to act on the property owner's behalf . have read this application and the information I have pro vided is corr ect . I agree to comply with all applicable city and county ordin ances and state l aws relating to building construction. I a uthoriz e r epr esentatives of this county to enter the above -identified property for i nspection purposes. Signature of Property Own er or Authoriz ed Agent