LADBS Self Certification Application

Please only fill out this application if you have the following documents ready to be uploaded, as they are required for review and processing.

Proof of Professional Architectural Licensure in the State of California
Proof of Insurance
Proof of ICC Certification under the California Residential Code Self-Certification Program
Certificate of Good Conduct
Passport Photo

Certification Title

Date

First Name

Middle Name

Last Name

Birth Date

House Number

Street Dir

e.g. E, N, S, W

Street Name

Street Suffix

e.g. Ave, Rd, St

Unit

City

State

Zip

Phone Number

ICC Certificate Number

International Code Council

Architect License Number

Architect License Issued Date

I hereby certify that all of the information that I have given herein is true and complete to the best of my knowledge and belief. I understand that any false statement will subject me to disqualification.

As a covered entity under Title II of the Americans with Disabilities Act, the City of Los Angeles does not discriminate on the basis of disability and, upon request, will provide reasonable accomodation to ensure equal access to its programs, services and activities.

New Self Certification Application