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STATE OF CALIFORNIA—STATE AND CONSUMSF16LERVICES AGENCY PETE WILSON, Governor a AIL State of TRACTORS STATE LICENSE B RD - IL. AM California 9835 GOETHE ROAD, SACRAMENTO, CALIFORNIA p of MAILING ADDRESS: P.O. BOX 26000 Conswilff SACRAMENTO, CALIFORNIA 95826 Affairs (916)366-5153 EXEMPTIONTI Pursuant to Section 7125.1 of the Business and Professions Code prior to issuance of a new license or reinstatement,reactiva- tion,or renewal of an existing license and as a condition of continued maintenance of an existing license,the applicant or licensee must have on file a Certificate of Workers'Compensation Insurance or a certificate of consent to self-insure from the Director of Industrial Relations. If the applicant or licensee has no employees,an exemption certificate must be submitted, certifying under penalty of perjury that he/she does not employ any person in any manner to be subject to the Workers' Compensation laws of California. A certificate or exemption is not required on an inactive license. If you do not employ any person in any manner to be subject to the Workers'Compensation laws of California,complete this exemption certificate. Send the completed certificate to the Contractors State License Board(CSLB)at the address above. NOTE:If the license is qualified by a Responsible Managing Employee(RUE),an exemption certificate cannot be submitted. PLEASE TYPE OR PRINT IN INK. FORMS COMPLETED IN PENCIL ARE NOT ACCEPTABLE. LICENSE NUMBER OR PENDING APPLICATION NUMBER 10,12 FULL NAME OF BUSINESS(AS IT CURRENTLY APPEARS ON THE RECORDS OF THE CSLB) aur h" Exca vw.k-S EFFECTIVE DATE—MONTH/DAY/YEAR.(IF THE EFFECTIVE DATE is OLDER THAN 90 DAYS,WE WILL USE THE TIIatE STAMP DATE) 1-1-q DAYTIME TELEPHONE NUMBER EVENING TELEPHONE NUMBER On 1~- c at Date-Mo/Day/Yr City County State I certify under penalty of petJmy under the laws of the State of California that the above named business does not employ any person in any manner so as to become subject to the Workers'Compensation laws of California. I further certify that the CSLB will be notified within 90 days of any change which results in the business becoming subject to the Workers' mpensatto awaof Califo 'a SIGNATURE OF OWN TNER OR OFFIC PRINT OR TYPE N b Yom... F THIS EXEMPTION WILL REMAIN ON FILE UNTIL YOU NO'T'IFY THE CSLB OF ANY CHANGES. PURSUANT TO SECTION 7083 OF THE BUSINESS AND PROFESSIONS CODE,FAILURE TO NOTIFY THE CSLB OF ANY CHANGES WITHIN 90 DAYS IS GROUNDS FOR DISCIPLINARY ACTION. 13L.50(7/91) q1 61587