Building Plan Self-Certification Registration Application
Licensed Professional
Name:
*
First Name
Last Name
Business Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
*
example@example.com
California License Type:
*
Registered Architect
Professional Engineer
License No.:
*
Expiration
*
-
Month
-
Day
Year
Date
Upload Copy of License
*
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License Standing
Has any state licensing board imposed disciplinary action against you over the past five (5) years?
*
Yes
No
If yes, please list actions taken against you:
Previous Work in Los Angeles County
Have you been responsible for ensuring Los Angeles County Building Code compliance over the past three (3) years?
*
Yes
No
If yes, please list a list of projects for which you’ve obtain building permits in Los Angeles County:
Professional Liability Errors and Omissions Insurance
Upload Copy of Insurance
*
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Insurer Infromation
Insurer Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurer Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
California License No.:
*
Policy Information
Policy No.:
*
Policy Expiration:
*
-
Month
-
Day
Year
Date
Amount per Claim:
*
Aggregate Amount:
*
Signature:
*
Please verify that you are a real person
*
Submit
INTERNAL USE ONLY (PUBLIC WORKS)
Status:
Please Select
Approved
Denied
Other
Status Notes:
Reviewer Name:
Review Date:
-
Month
-
Day
Year
Date
Should be Empty: