Hayward Fire Department
I hereby affirm that I am licensed under provisions of
Chapter 9 (commencing with Sec. 7000 of div. 3 of the Business
and professions Code, B&P c) and my license is in full force and
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason: Sec. 703.5 B&PC. Any city
or county which requires a permit to construct, alter, improve,
demolish, or repair any structure, prior to its issuance also requires
the applicant for such permit to file a signed statement that
applicant is licensed pursuant to the provisions of the Contractor's
License Law (Chapter 9 commencing with Sec. 7000 of Div. 2 of
the B&PC) or is exempt there from and the basis for the alleged
exemption. Any violation of Section 7031.5 by an applicant for a
permit subjects the applicant to a civil penalty of not more than five
hundred dollars. ($500.00)
sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, B&PC). The Contractor's
License Law does not apply to an owner of property who builds or
improves thereon and who does such work himself or through his
own employees, provided that such 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 providing that he did not build or
improve for the purpose of sale.
I, as owner of the property, or my employees with wages as
licensed contractors to construct the project in conformance with
Sec. 7044, B&PC. Subject to certain limitations, the Contractor's
License Law does not apply to an owner of property who builds or
improves thereon, and who contracts for each project with a
contractor(s) licensed pursuant to the Contractor's License Law.
I, as owner of the property, am exclusively contracting with
I am exempt under Sec. B&PC for this reason:
Worker's Compensation
I hereby affirm that I have a certificate of consent to self-
insure, or a certificate of Workers' Compensation Insurance, or a
certified copy thereof (Sec. 38000, Labor Code). INSURANCE
Copy is filed with the City.
Certified copy is hereby furnished.
Certificate of Exemption from Workers' Compensation
This section need not be completed if the permit is for one
hundred dollars ($100.00) or less.
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
Fire Permit No.:
Bldg. Permit No.:
Project Name:
Job Address: Apt/Suite
City: State: Zip Code:
Fee: (Dept. Use Only)____
Description of Proposed Work:
Property Owner:
Address: Apt/Suite
City: State: Zip Code:
Is Owner Applicant? YES NO
Applicant Name:
Address: Apt/Suite
City: State: Zip Code:
Office Phone: ______ FAX:
Contractor's Business Name:
City:_____________________State:_________ Zip Code:
California State License No. / Class:
Hayward Business License No:
I certify that I have read this application and state that all information
provided is correct. I agree to comply will all city and county
ordinances and state laws relating to building construction, and
hereby authorize representatives of the City of Hayward to enter upon
the job location for inspection purposes.
Fire Prevention - Hazardous Materials
777 B. Street, Hayward, California 94541, 510-583-4900 FAX 510-583-3641
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