Address: Project #:
1. OWNER-BUILDER’S 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.
Property Owner or Authorized Agent signature Date
2. 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 the work for
which this permit is issued. My workers’ compensation insurance carrier and policy number are:
Carrier Policy No Exp Date
Name of Agent Tel No
(_) 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.
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
($100,000.00), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706
OF THE LABOR CODE, INTEREST, AND ATTORNEY’S FEES.
3. 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
By my signature below, I certify to each of the following:
• I have read this construction permit application and the information I have provided is true and correct.
• I agree to comply with all applicable Long Beach City, 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.
I am (__) the property owner or (__) authorized agent acting on the property owner’s behalf.
The Notice to Property Owner form shall accompany this document. The property owner must complete the Authorization of Agent
section on the form when an authorized agent is acting on the property owner’s behalf.
Signature Date
Page 2 of 2
To request this information in an alternative format or to request a reasonable accommodation, please contact the
Development Services Department at longbeach.gov/lbds and 562.570.3807. A minimum of three business days
is requested to ensure availability; attempts will be made to accommodate requests with shorter notice.
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