Site Address: ___

I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason (Sec.7031.5 California Business and Professions Code(B&PC)): Any City 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 he/she is licensed pursuant to the provisions of the Contractor's License Law (Ch.9 (commencing with Sec. 7000) of Div. 3 of the B&PC) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violations of Sec. 7031.5 by any applicant for a permit subject to the applicant to a civil penalty of not more than five hundred dollars ($500.00).

I hereby affirm under penalty of perjury, one of the following declarations (SELECT ONE):

I, as owner of the property, or my employees with wages as their 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 any 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 proving he did not build or improve for the purpose of sale.)

I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, B&PC: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)

I am exempt under Sec. _____, of B&PC for this reason:

I am exempt under Sec. ___, of B&PC for this reason:

I hereby affirm 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.

Name: ___

Lic. No.: _____ Class: _____

Exp. Date: ___

Address: ___

Rep.: _____ Tel. No.: _____

Email: ___

I hereby affirm under penalty of perjury, one of the following declarations (SELECT ONE):

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.

I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by Sec. 3700 of the Labor Code, for the performance of the work for which this permit is issued.

I have and will maintain workers' compensation insurance as required by Sec. 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: ___

Date: ___/___/___ Applicant: ___

Date: ___/___/___ Owner: ___

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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 certify that I have read this application and state that the above information is correct. I agree to comply with all City and State laws relating to the building construction and hereby authorize representatives of the City to enter upon the above-mentioned property for inspection purposes. I also understand that utilities will not be released until such times as all laws, codes and special conditions are completed and accepted by the City. By signing this application, I attest that the property owner has granted consent to apply for the permit and that the associated plans can be released to the property owner at any time.

Date: ___/___/___ Name: ___

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