CALBO Jan 1, 2009 Permit Application Template – modified for City of Moorpark
Issue Date: 4/22/2020
Page 2 of 2
I, as owner of the property, am exclusively contacting with licensed Contractors to construct the project (Section
7044, Business and Professions Code: The Contractors’ State Licnse Law does not apply to an owner of property who builds
or improves thereon, and who contracts for the projects with a licensed Contractor pursuant to the Contractors’ State License
I am exempt from licensure under the Contractors’ State License Law for the following reason:
By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one
year prior to completion of the improvements covered by this permit, I cannot legally sell a structure that I have built as an
owner-builder if it has not been constructed in its entirety by licensed contractors. I understand that a copy of the applicable
law, Section 7044 of the Business and Professions Code, is available upon request when this application is submitted or at
the following Web site: http://www.leginfo.ca.gov/calaw.html.
Property Owner or Authorized Agent Name:
Property Owner or Authorized Agent signature: _______________________________________ Date: ______________
#3 IDENTIFY WORKERS’ COMPENSATION COVERAGE AND LENDING AGENCY
WARNING: FAILURE TO SECURE WORKERS’ COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER
TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE NUMDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST
OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY’S FEE.
WORKERS’ COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self-insure for workers’ compensation, issued by the Director of
Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. Policy No: ___________________________
I have and will maintain workers’ compensation insurance, as required by Section 3700 of the Labor Code, for the
performance of work for which this permit is issued. My workers’ compensation insurance carrier and policy number are:
Carrier: ______________________________ Policy No: __________________ Expiration Date: ________________
I certify that, in the performance of the work for which this permit is issued, I shall not employ any person in any
manner so as to become subject to the workers’ compensation laws of California, and agree that, if I should become
subject to the workers’ compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for
which this permit is issued (Section 3097, Civil Code).
Lender’s Name and Address: _________________________________________________________________________
#4 DECLARATION BY CONSTRUCTION PERMIT APPLICANT
By my signature below, I certify to each of the following:
I am a California licensed contractor I am the property owner *
I am authorized to act on the property owner’s behalf **.
I have read this construction permit application and the information I have provided is correct.
I agree to comply with all applicable city and county ordinances and state laws relating to building construction.
I authorize representatives of this city or county to enter the above-identified property for inspection purposes.
California Licensed Contractor, Property Owner* or Authorized Agent**
Print Name: Signature:
* Requires separate Verification Form. ** Requires separate Authorization Form