DEPARTMENT OF COMMERCE OWNER/BUILDER CERTIFICATION
Division of Occupational and and
Professional Licensing AGREEMENT TO COMPLY WITH THE
Bureau of Investigation CONSTRUCTION TRADES LICENSING ACT
160 E 300 S
PO Box 146741
Salt Lake City UT 84114-6741
Email to colleengonzalez@utah.gov
[ ] New Residential Construction Permit #_______________
[ ] Remodel or Addition by Owner
Description of Remodel or Addition________________________________________________________
Name of Owner/Builder: ___________________________________________________________________________________
Current Address: _________________________________________________________________________________________
City, State, Zip: ___________________________________________________________________________________________
LOCATION OF CONSTRUCTION SITE:
Address: ________________________________________________________________________________________________
City, State Zip: ___________________________________________________________________________________________
Subdivision: _____________________________________________________________________ Lot No. _________________
CERTIFICATION
I, ___________________________, certify under penalty of perjury that the following statements are true and correct and are based
upon my understanding of the Utah Construction Trades Licensing Act:
1. For New Residential Construction Only. I am the sole owner of the property and construction project at the above
described location; the project described is the only residential structure I have built this year; I have not built more than
three residential structures in the past five years.
For New Residential and Remodel Construction:
2. The improvements being placed on the property are intended to be used and will be used for my personal, non-
commercial, non-public use:
3. I understand that work performed on the project must be performed by the following:
a. myself as the sole owner of the property; or
b. a licensed contractor; or
c. my employee(s) on whom I have Workers Compensation Insurance coverage, on whom I withhold and pay all
required payroll taxes, and with respect to whom I comply with all other applicable employee/employer laws; or
d. any other person working under my supervision as Owner/Builder to whom no compensation or only token
compensation is paid; and
4. I understand that if I retain the services of an unlicensed contractor or compensate an unlicensed person, other than
token compensation, or other than as an employee for wages, to perform construction services for which licensure is
required, I may be guilty of a Class A Misdemeanor and may be additionally subject to an administrative fine in the maximum
of $2,000.00 for each day on which I violate the Utah Construction Trades Licensing Act.
I declare under criminal penalty under the law of Utah that the foregoing is true and correct.
Signed on the __ _ day of ___ ___, __ ___, at ________ ________________________.
Date Month Year City or other location, and state or country
_ ____________________ __ _ _______________________
Printed Name Signature
SUBMIT THIS FORM TO THE BUILDING DEPARTMENT TO OBTAIN
NECESSARY BUILDING PERMITS.
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