LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and effect.
License Class: License No.: Contractor Signature: ______________________________________ Date: ________________
OWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the reason(s) indicated below by the checkmark(s)
I have placed next to the applicable item(s) (Section 7031.5, Business and Professions Code: Any city or county that requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is
licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code) or that he or she is exempt from licensure and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for
a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).):
____ I, as owner of the property, or my employees with wages as their sole compensation, will do (___) all of or (___) portions of the work, and the
structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Contractors' State License Law does not apply to an
owner of property who, through employees' or personal effort, builds or improves the property, provided that the improvements are not intended or
offered for sale. If, however, the building or improvement is sold within one year of completion, the Owner-Builder will have the burden of proving that it
was not built or improved for the purpose of sale.).
____ I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section 7044, Business and Professions
Code: The Contractors' State License 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 Law.).
____ 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
Signature of Property Owner or Authorized Agent: ___________________________________________________________ Date: ________________
WORKERS' COMPENSATION DECLARATION
Carrier:
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 provisions.
Signature of Applicant: _________________________________________________________________________________ Date: ________________
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: Lender's Address:
CERTIFICATION, AGREEMENT AND AUTHORIZATION
Policy Number:
Expiration Date:
Name of Agent: Phone:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED 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 FEES.
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 the work for which
this permit is issued. My workers' compensation insurance carrier and policy number are:
I certify that I have read this application and state that the information is correct. I agree to comply with all city and county ordinances and state laws relating
to building construction and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes.
Signature of Applicant: ____________________________________ Print Name: ____________________________________ Date: ________________
August 2013
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