Public Health Permit Attestation {LIC-4025}

LIC-4025-FORM - ATTESTATION: PUBLIC HEALTH, BUILDING & OPERATING PERMITS. This form is issued by the City of Los Angeles Department of Cannabis Regulation (DCR) and is used to document and confirm a cannabis business licensee’s compliance with a series of regulatory milestones required to maintain Temporary Approval and/or an Annual License for calendar years 2026 through 2029. The form must be completed and submitted along with supporting documents during the license renewal process. It includes two attestations. Attestation No. 1 requires the licensee to confirm that they have submitted building plans to the Los Angeles Department of Building and Safety (LADBS), obtained a Public Health Permit, received all necessary clearances and permits, and secured either a Building Permit or Certificate of Occupancy by specific deadlines set forth in DCR Regulation Nos. 5(A)(8) and (9). Attestation No. 2 serves as a general acknowledgment of the licensee’s understanding of these requirements, confirming that failure to comply may lead to license denial, suspension, or violations. Signatures from a majority (51%) of Level 1 Owners—those who directly own the business without intermediaries—are required to validate the form. www.FormsWorkflow.com