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 Licensure in the State of California
Proof of Insurance
Proof of ICC Certification under the California Residential Code Self-Certification Program (*Required for Residential)
Certificate of Good Conduct
Passport Photo

Professional Certification Title (change) Please select at least one checkbox for the 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

Professional License Number

Professional License Issued Date

ICC Certificate Number

International Code Council (*Required for Residential)

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

License Type