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CONTRACTORS STATE LICENSE BOARD STATE OF CALIFORNIA ` 9821 Business Park Drive,Sacramento,Califomia 95827 Governor Edmund G.Brown Jr. I Mailing Address:P.O.Box 26000,Sacramento,CA 95826 800-321-CSLB(2752) www.cslb.ca.gov•CheckTheticenseFirst.com Exemption from Workers' Compensation Before the Contractors State License Board(CSLB)can issue a new license or reinstate,reactivate,or renew an existing license,the applicant or licensee must have on file a Certificate of Workers'Compensation Insurance or a Certificate of Self-Insurance issued by the Director of Industrial Relations,or must obtain an exemption by completing and submitting this form. To be exempt from workers'compensation,an applicant or licensee must submit this form to CSLB,certifying under penalty of perjury that he or she does not employ anyone in a manner that is subject to the workers'compensation laws of California. (See Business and Professions Code Section 7125.) DO NOT SUBMIT THIS FORM IF: • You have an inactive license. • The license qualifier is a Responsible Managing Employee(RME). ■ You hold a C-39 Roofing classification—all contractors with a C-39 Roofing classification are required by Section 7125 to have a Certificate of Workers'Compensation Insurance or a Certificate of Self-Insurance on file with the Board. Contractors with a C-39 Roofing classification are not eligible for exemption from workers'compensation. • You have employees. For exemption from workers'compensation,complete all of the requested information in Section 1,check only one of the boxes in Section 2,and date and sign the form in Section 3. Please type or print neatly and legibly in black or dark blue ink. SECTION 1 —REQUIRED BUSINESS NAME AND ADDRESS Brjsiness Name(as it curr n Iy appears on CSLB records) License or Application Fee Number ( Vn)D 10S C 'tel 11(TI i� 7 ;� G : / RZ3 Business Mailing Address(number/street or P. .box) _ �tY State Zip Code Business Street Address(numberlstreet only—NO P.O.boxes) City State Zip Code Business Phone Numbert Business Fax Number Business E-mail Address ` 00 cl )`�( / - /is1/�/ J( ) rWiCo, (3i'cs h Cc!l� ❑ Check this box if the address shown above is new. CSLB will update your license t application business address of record. SECTION 2—REQUIRED CHECK BOX YOU MUST CHECK ONLY ONE OF THE BOXES BELOW. I do not employ anyone in the manner subject to the workers'compensation laws of California. OR ❑ 1 am an out-of-state contractor,and I do not hire employees who reside in California. (You must provide a certificate of insurance from your workers'compensation insurance carrier in your home state.) SECTION 3—REQUIRED SIGNATURE I certify under penalty of perjury under the laws of the State of California that the information provided on this exemption statement is true and accurate. I understand that,upon employing anyone in a manner that is subject to the workers'compensation laws of the State of California,the claim of exemption executed under this form will no longer be valid. I also understand that,as soon as I employ anyone subject to the California's workers'compensation laws,I must obtain a Certificate of Workers'Compensation Insurance,submit that certificate to CSLB within 90 days of its effective date,and continuously maintain the coverage provided by the certificate in accordance with the law. I further understand that failure to comply with this requirement is grounds for disciplinary action.(The definition of perjury"is telling a lie while under oath.) FALSIFICATION OF ANY DO�qMENT IS GROUNDS PR DISCIPLINARY ACTION. Dae Sig a um'of Contractor(Owner,Partner,or Officer) Printed Name of Contractor(Owner,Partner,or Officer) -- , c NOTICE ON COLLECTION of PE ONAL INFORMATION CSLB collects the personal information requested on this form as authorized by Business and Professions Code Section 30 CSLB use—1 information to identify FOR CSLB USE ONLY and evaluate applicants for licensure,issue and renew licenses,and enforce licensing standards set by law and egulation. Submission of the requested information is mandatory. CSLB ci3nno`t consider this Exemption from Workers compensation form unless you provide all of the requested information. You may review the records maintained by CSLB that contain your personal information,as permitted by the Information Practices AcL CSLB makes every effort to protect the personal information you provide us;however,it may be disclosed in response to a Public Records Act request as allowed by the Information Practices Act;to another government agency as required by state or federal law;or in response to a court or administrative order,a subpoena,or a search warrant. This application contains an applicant authorization for the Franchise Tax Board to disclose to CSLB any outstanding final liabilities for the purpose of administenng Business and Professions Code section 7145.5. For more information on the Information Pmcfices Ad,visit the Office of Privacy Protection's website at wrvvw.privacy.ca.gov. I(IIIIII III III�I�III I�IIIII II�III VIII VIII I 13L-50(rev.4111) IIIIIW C - E X E M P TIMI