West Covina, CA · Los Angeles County
Owner-Builder Declaration, Workers Compensation Declaration and Authorization of Entry
Property owners complete this form to apply for an owner-builder building permit and acknowledge their responsibilities for the construction project.
What this form is
The property owner must complete and sign this form before the city can issue an owner-builder permit. It records the project address and permit number, explains owner-builder responsibilities, authorizes city inspection entry, and asks the signer to make a workers’ compensation declaration. The signer provides insurance details if applicable, then prints their name and dates the form.
Who needs it
Property owners seeking an owner-builder building permit must complete and sign this form before the permit can be issued.
How to submit it
Complete and sign the form before an owner-builder permit is issued; the document identifies the building department as its issuer. It provides no submission address, email, portal, or fee.
About notarization
This document is signed without a notary; the workers’ compensation declaration is affirmed under penalty of perjury, and the signer prints their name and dates it.
How to submit this form
- 1
Download the Form
Download the Owner-Builder Declaration PDF.
- 2
Complete the Form
Enter the project address and permit number, then complete the owner-builder and workers’ compensation declarations.
- 3
Add Insurance Details
If applicable, provide the workers’ compensation certificate number, insurance carrier, policy number, and expiration date.
- 4
Sign and Date
Print your name to sign the declarations and authorization of entry, then enter the date.
- 5
Submit to the City
Complete and sign the form before the owner-builder permit is issued; the document identifies the building department as its issuer.
Frequently asked questions
- Do I need a notary for the Owner-Builder Declaration?
- No. The form has no notary block; the workers’ compensation declaration is affirmed under penalty of perjury, and the signer prints their name and dates it.
- Who completes the Owner-Builder Declaration?
- The property owner completes and signs the form before an owner-builder permit can be issued. It records the project address and the owner’s declarations.
- How do I submit the Owner-Builder Declaration?
- The form says it must be completed and signed before the owner-builder permit is issued and identifies the building department as its issuer. It gives no submission address or method.
Need something notarized?
This Owner-Builder Declaration, Workers Compensation Declaration and Authorization of Entry doesn’t need a notary — but if you have another West Covina form that does, a commissioned online notary can help.