CONTRACTORS STATE LICENSE BOARD

9821 Business Park Drive, Sacramento, CA 95827 Mailing Address: P.O. Box 26000, Sacramento, CA 95826 800.321.CSLB (2752) | www.cslb.ca.gov | CheckTheLicenseFirst.com

STATE OF CALIFORNIA Governor Edmund G. Brown Jr.

IMPORTANT NOTICE REGARDING CONVICTIONS

PLEASE READ CAREFULLY
Failure to accurately report a conviction can result in an application being denied. In this notice and on the application, the term
conviction includes pleading guilty or no contest to (nolo contendere) or being convicted by a court of any misdemeanor or felony in this state or elsewhere. As part of the CSLB application process, you must be fingerprinted if you have not been fingerprinted by CSLB before or if your previous fingerprint record was purged by CSLB due to a voided application or some other reason. After an application is accepted by CSLB as complete (also known as posted), each individual listed on the application will be sent instructions on the process for obtaining and submitting fingerprints, as required by law. Your fingerprints will be compared to the records of the California Department of Justice and the Federal Bureau of Investigation. If you have ever been convicted of a crime, your criminal record information will be reported to CSLB. This includes DUIs and other Vehicle Code violations resulting in a misdemeanor or felony conviction. Even if you have had your record expunged (charges reduced or dismissed), the past conviction will still be reported to CSLB and must be disclosed on the application. If you have ever been convicted of a crime (misdemeanor or felony), you MUST answer Yes to the criminal conviction question on the application and provide a detailed explanation of the circumstances resulting in your conviction. To help ensure that you provide the required information, you should complete and submit the Disclosure Statement Regarding Criminal Plea/Conviction form that is available on CSLBs website. Applicants with criminal convictions are not automatically denied licensure each application is reviewed individually based on applicable sections of law. When reviewing criminal convictions, CSLB considers factors such as the nature and severity of the crimes, the amount of time that has passed since the convictions, and any evidence of rehabilitation submitted by the applicant. For rehabilitation evaluation, pursuant to the California Code of Regulations Section 869, CSLB is generally looking for three (3) years to have passed after a misdemeanor conviction and seven (7) years to have passed after a felony conviction, without further violation of law. These timeframes are calculated from the applicants date of release from incarceration or from the end of probation if no time was served, and are subject to reduction or extension based on several factors, including the nature of the applicants conviction history as a whole. In addition, any type of conviction could be considered substantially related to the qualifications or duties of a contractor license when evaluated in the context of the applicants entire conviction record. Failure to accurately report any and all convictions is falsification of your application and is grounds for denial. If your application is denied, you will be prevented from filing another application for a minimum of one (1) year, up to a maximum of five (5) years.
13A-1 (rev. 06/11)

CONTRACTORS STATE LICENSE BOARD

9821 Business Park Drive, Sacramento, CA 95827 Mailing Address: P.O. Box 26000, Sacramento, CA 95826 800.321.CSLB (2752) | www.cslb.ca.gov | CheckTheLicenseFirst.com

STATE OF CALIFORNIA Governor Edmund G. Brown Jr.

IMPORTANT NOTICE
Dear Applicant: Enclosed is the application you requested from the Contractors State License Board (CSLB). Please be aware that nearly half of all applications submitted to CSLB are incomplete and must be rejected!

You must complete your application in its entirety for it to be accepted by CSLB. After an application has been accepted by CSLB as
complete (also known as posted), each individual listed on the application will be sent instructions on the process for obtaining and submitting fingerprints as required by law. An incomplete application can needlessly delay your license. Delays can last several weeks or even months and possibly result in the application being voided and the application fee being forfeited.

Spending a few extra minutes now may save you weeks or months later!
Before you submit your application, follow these simple directions. Sign the forms. Fill out all applicable information. Make sure you submit Certification of Work Experience forms that have been filled out completely, ensuring that you have provided four (4) years of applicable experience in the classification for which you are applying. Carefully read the General Information section that immediately precedes the application package and follow the specific instructions that are contained throughout the application package to help ensure that your application is complete. Please be aware that there are no schools or application preparation organizations that are affiliated with or agents of CSLB, although some may have company names that are confusingly similar to CSLB. If you discover that an organization has misrepresented itself as being CSLB, you should submit a complaint to CSLB or the California Department of Consumer Affairs. Official CSLB examination study guides are available free of charge on CSLBs website and are mailed to applicants when they are scheduled for exams.

13A-1 (rev. 06/11)

CONTRACTORS STATE LICENSE BOARD

9821 Business Park Drive, Sacramento, CA 95827 Mailing Address: P.O. Box 26000, Sacramento, CA 95826 800.321.CSLB (2752) | www.cslb.ca.gov | CheckTheLicenseFirst.com

STATE OF CALIFORNIA Governor Edmund G. Brown Jr.

APPLICATION FOR ORIGINAL CONTRACTOR LICENSE

General Information

Listed below is general information to assist you as you complete the attached application. Detailed instructions are provided throughout the application package. Please refer to the Contractors State License Boards (CSLB) publication Blueprint for Becoming a Licensed Contractor for more detailed information about the licensing process. To receive a copy of Blueprint, please contact CSLB or visit the Guides and Pamphlets page on CSLBs website. Do not submit this General Information section with your completed application the actual application begins immediately following this section on Application Page 1 of 3 and includes the Certification of Work Experience and the Construction Project Experience form, if needed. Before you submit your application, please review and check off the following items.

Enclose the nonrefundable $300 application fee with your completed application. CSLB cannot process your application without the appropriate fee made payable to the Registrar of Contractors. (The $180 initial license fee should be submitted separately after you pass the examination.) Your application may be returned to you if it is insufficient or incomplete. You must provide any missing information, make corrections, and resubmit your completed application to CSLB within 90 days after the date that it was returned to you or your application will become void. You cannot reinstate a void application you must submit a new application and $300 application fee if you wish to pursue licensure. Complete the application and all accompanying forms legibly in black or dark blue ink, with a typewriter, or on CSLBs website using the form-fill feature. Forms completed in pencil will be returned to you. Please make sure that you and other appropriate individuals sign and date the forms, where applicable. Full legal names are required. You must provide the full legal name of all personnel. If an individual does not have a middle name, write None or No Middle Name in the space provided. If an individual has only an initial for his or her first or middle name, write (Initial Only) after the initial. Leave no space blank. If a particular question or request for information does not apply to you, write N/A in the blank space to indicate that the question has received your attention but that it is not applicable. You must provide a street address for both your business and residence. P.O. Boxes and private mail boxes (PMB) are not acceptable for the street address. You must complete the personnel information requested in Section 4 on page 2 of the application for each individual who will be listed on the license. U.S. Social Security numbers are required for all applicants (see page 4 of this General Information section for information on the collection of Social Security numbers).

The # symbol is used interchangeably with the word number where space is limited on the application. The terms qualifying individual and qualifier are used interchangeably. The qualifying individual is the person who meets the experience and examination requirements for the license and who is responsible for the employers or principals construction operations. A qualifying individual is required for every classification on every license issued by CSLB. The qualifying individual may or may not be the owner of the business. (See California Contractors License Law & Reference Book, Ch. 1; or Blueprint for Becoming a Licensed Contractor, Questions 49-53.) If you need additional copies of forms (e.g., Certification of Work Experience, Section 4 Personnel Full Legal Names and Addresses), please make copies of the blank forms before you begin or print additional copies from CSLBs website. Please be aware that CSLB will begin accepting applications for licensure from limited liability companies (LLC) no later than January 1, 2012. A separate application will be available on CSLBs website for LLC applicants. FINGERPRINT REQUIREMENT All applicants for licensure are required to submit a full set of fingerprints for the purpose of conducting a criminal background check. Fingerprints will be compared to the records of the California Department of Justice and the Federal Bureau of Investigation to determine whether a criminal history exists. After an application has been accepted by CSLB as complete (also known as posted), each individual listed on the application will be sent instructions on the process for obtaining and submitting fingerprints as required by law. For more information, please visit CSLBs website and view information under the Applicants tab. Please detach this General Information section before submitting the completed application package to CSLB. 13A-1 (rev. 06/11) General Information Page 1 of 4

APPLICATION FOR ORIGINAL CONTRACTOR LICENSE

General Information

EXAMINATION ELIGIBILITY REQUIREMENTS

The qualifying individual for a contractor license is required to pass the written Law and Business Examination and a specific trade examination if required, unless he or she meets the requirements for a waiver (see next page for information regarding examination waivers). To be eligible to take an examination, the qualifying individual must have had, within the last 10 years, at least four (4) full years of experience in the classification for which he or she is applying. The experience must be at no less than a journeyman level, or as a foreman, supervisor, contractor, or owner-builder. A journeyman is defined as an experienced worker who is fully qualified (as opposed to a trainee, helper, laborer, assistant, apprentice, etc.) and is able to perform the trade without supervision, or a person who has completed an apprenticeship program. Experience is documented on the Certification of Work Experience form (see below). CSLB may grant up to three years of credit toward the four-year requirement for completed education and/or apprenticeship programs. Education/apprenticeship is documented in Section 6 of the application. CERTIFICATION OF WORK EXPERIENCE FORM The Certification of Work Experience form must be completed by the qualifier and certified by a person who has direct knowledge of the experience and time period listed. The experience must be verifiable through payroll records or similar documents. Corrections on the Certification forms must be initialed by the certifier. Forms containing strikeouts or modifications that may compromise the validity of the work experience certification may not be accepted. To assist the certifier in completing Part 2 of the Certification of Work Experience form, the Description of Classifications document is available through a link on the home page of CSLBs website. This document may be used as a reference only the certifier should not copy directly from the document when listing the specific trade duties that the qualifier has performed or supervised in the classification for which he or she is applying. The Certification of Work Experience form may not be required if the qualifier: has ever served as the qualifier on a license in the same classification for which he or she is applying; or has passed both the Law and Business Examination and the trade exam for the same classification within the last five (5) years. RE-EXAMINATIONS If you are required to take an examination, subject to some limitations, you have 18 months after the approval of your application in which to achieve a passing grade on the exam. During that time period, you may take the exam an unlimited number of times. A $60 fee is required each time you reschedule an exam. (See Business and Professions [B&P] Code Section 7074 for more detailed information on re-examinations.) TRANSLATOR FOR EXAMINATION If you have difficulty understanding or reading the English language, CSLB may allow you to use a translator to read the examination for you. The translator you choose must be approved in advance by CSLB. If you would like to use a translator during your examination, please check the box near the bottom of Section 3 on page 1 of the application and information will be sent to you regarding the process. REASONABLE ACCOMMODATION THE AMERICANS WITH DISABILITIES ACT In compliance with the Americans with Disabilities Act (ADA), CSLB provides reasonable accommodation for applicants with disabilities that may affect their ability to take the required examinations. Applicants wishing to request reasonable accommodation pursuant to the ADA must complete the Special Accommodation Request for Examination form (available on the Forms and Applications page on CSLBs website) and submit it to CSLB with the appropriate supporting documentation. In order to make the necessary arrangements to accommodate candidate needs, the form and supporting documentation should be submitted as soon as possible. BUSINESS ENTITY Applicants must designate their business entity sole owner, partnership, or corporation (joint ventures and limited liability companies must use a separate application). Applicants cannot change business entity after the application is submitted. Corporations must be registered with the California Secretary of State and in good standing prior to being issued a contractor license. The Secretary of State can be reached by calling (916) 653-6814 or by visiting their website at www.sos.ca.gov. Corporations must provide a current and active registration number on the application. All corporations must also provide the name(s) of their corporate officer(s): California corporations president, secretary, and treasurer; foreign corporations president only. Please be sure to write these titles in the space provided for the appropriate personnel in Sections 3 and 4 and be sure that they match those listed in the Secretary of State records. Please detach this General Information section before submitting the completed application package to CSLB. 13A-1 (rev. 06/11) General Information Page 2 of 4

APPLICATION FOR ORIGINAL CONTRACTOR LICENSE

General Information

Partnerships must list their Federal Employer Identification Number (FEIN), which is available from the U.S. Internal Revenue Service (IRS). The IRS can be reached by calling (800) 829-1040. Personal Social Security numbers are not acceptable for the FEIN. EXAMINATION WAIVERS The examination is waived if the qualifying individual is currently, or has been in the last five years, actively engaged in the construction business and meets specific waiver requirements as mandated by law. (See B&P Code Sections 7065.17065.4.) In addition, the trade examination may be waived if the qualifier meets the requirements for reciprocity based on licensure in the same classification in Arizona, Nevada, and/or Utah (see CSLBs website for more information on reciprocity under the Applicants tab). If you are applying for a waiver of the examination, you should complete the Application for Original Contractor License Examination Waiver (7065). LIMITED PARTNERS A Limited Partner is responsible for the business only in proportion to the amount of his or her financial interest; however, he or she does not participate in the daily operation of the business. If a member of the personnel is listed on the application as a Limited Partner, he or she cannot, in the future, be granted a waiver of the examination or a license continuance. CONTRACTOR CLASSIFICATIONS Listed below are the contractor license classifications. For a complete description of the classifications, refer to the Description of Classifications document available through a link on the home page of CSLBs website. General Engineering .................................................. A
General Building......................................................... B
Boiler, Hot-Water Heating, and Steam Fitting............ C-4
Building Moving/Demolition........................................ C-21
Cabinet, Millwork, and Finish Carpentry .................... C-6
Ceramic and Mosaic Tile............................................ C-54
Concrete..................................................................... C-8
Construction Zone Traffic Control .............................. C-31
Drywall........................................................................ C-9
Earthwork and Paving ................................................ C-12
Electrical..................................................................... C-10
Elevator ...................................................................... C-11
Fencing....................................................................... C-13
Fire Protection ............................................................ C-16
Flooring and Floor Covering....................................... C-15
Framing and Rough Carpentry................................... C-5
General Manufactured Housing ................................. C-47
Glazing ....................................................................... C-17
Insulation and Acoustical ........................................... C-2
Landscaping ............................................................... C-27
Lathing and Plastering ............................................... C-35
Limited Specialty (see below) .................................... C-61
Lock and Security Equipment .................................... C-28
Low Voltage Systems................................................. C-7
Masonry ..................................................................... C-29
Ornamental Metal....................................................... C-23
Painting and Decorating............................................. C-33
Parking and Highway Improvement ........................... C-32
Pipeline ...................................................................... C-34
Plumbing .................................................................... C-36
Refrigeration............................................................... C-38
Roofing ....................................................................... C-39
Sanitation System ...................................................... C-42
Sheet Metal ................................................................ C-43
Sign ............................................................................ C-45
Solar ........................................................................... C-46
Steel, Reinforcing....................................................... C-50
Steel, Structural.......................................................... C-51
Swimming Pool .......................................................... C-53
Warm-Air Heating, Ventilating, and Air-Conditioning. C-20
Water Conditioning..................................................... C-55
Welding ...................................................................... C-60
Well Drilling (Water) ................................................... C-57

The C-61 Limited Specialty classification is for contractors who specialize in work not listed above (for example, D-50
Suspended Ceilings) or who perform work that is a specialized part of an existing classification (for example, D-29 Paper
Hanging). The Description of Classifications document contains a full listing of the subcategories of the C-61
classification.
BOND AND INSURANCE REQUIREMENTS Please refer to CSLBs website (including Blueprint for Becoming a Licensed Contractor) for information on the bond and insurance requirements for licensure. For more detailed information on bonds, refer to A Guide to Contractor License Bonds, which can be viewed on the Guides and Pamphlets page of CSLBs website. Please detach this General Information section before submitting the completed application package to CSLB. 13A-1 (rev. 06/11) General Information Page 3 of 4

APPLICATION FOR ORIGINAL CONTRACTOR LICENSE

General Information

REISSUANCE OR REASSIGNMENT OF LICENSE NUMBER If the qualifier has previously been licensed, it may be possible to have the previous license number reissued or reassigned under certain circumstances. (See B&P Code Section 7075.1 and Form 13A-1h.) CONSTRUCTION MANAGEMENT EDUCATION ACCOUNT A grant program was established in 1991 to provide funds for qualified public post-secondary schools that teach construction management. Applicants may voluntarily contribute to the account when paying the application fee or the license renewal fee. If you would like to make a voluntary contribution, please mark the box on the top portion of page 1 of the application, write in the dollar amount in the space provided, and include that dollar amount in the total amount paid with your application, or submit a separate check or money order made payable to CSLB/Construction Management Education Account. (See B&P Code Section 7139, Article 8.5.) COLLECTION OF SOCIAL SECURITY NUMBERS With the exception of the driver license numbers, all information requested on the application is mandatory, including disclosure of U.S. Social Security numbers (SSN). Collection of the SSN is authorized by B&P Code Section 30 and Public Law 94-455 (42 U.S.C.A. 405(c)(2)(C)). SSNs are used exclusively for the purpose of tax enforcement and/or compliance with any judgment or order for family support in accordance with Family Code Section 17520. If you fail to disclose your SSN, you will be reported to the Franchise Tax Board, and they may assess a $100 penalty against you. The official responsible for the maintenance of this information is the Registrar of Contractors, Contractors State License Board. The information may be transferred to other state or government agencies. Individuals have the right to review files or records about them maintained by the agency, unless the records are identified as confidential information and exempted from the Information Practices Act, Civil Code Section 1798.3. COLLECTION OF PERSONAL INFORMATION CSLB collects the personal information requested on the following forms as authorized by B&P Code Section 30 and California Code of Regulations (CCR) Section 816. CSLB uses this information to identify and evaluate applicants for licensure, issue and renew licenses, and enforce licensing standards set by law and regulation. Submission of the requested information is mandatory. CSLB cannot consider your application for licensure or renewal 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 Act. 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. The application contains an applicant authorization for the Franchise Tax Board to disclose to CSLB any outstanding final liabilities for the purpose of administering B&P Code Section 7145.5. For more information on the Information Practices Act, visit the Office of Privacy Protections website at www.privacy.ca.gov, or call (866) 785-9663. RESOURCES ON THE LICENSING PROCESS CSLB has a variety of publications available to help you become a licensed contractor and to maintain your license. You can order free publications from CSLBs website (www.cslb.ca.gov), by writing to CSLB at the address listed below, or by calling the 24-hour automated phone system at (800) 321-CSLB (2752). CSLB publications that can help you understand the licensing process include Blueprint for Becoming a California Licensed Contractor, Description of Classifications, Building Your Career, and A Guide to Contractor License Bonds. Please visit CSLBs website or call the toll-free phone number to find out how to order the current edition of the California Contractors License Law & Reference Book. APPLICATION PROCESSING When CSLB receives your application, an acknowledgement letter will be sent to you that explains how to check the status of your application online at www.cslb.ca.gov or by calling (800) 321-CSLB (2752) using the Application Fee Number and Personal Identification Number (PIN) provided in the acknowledgement letter. After an application has been accepted by CSLB as being complete (also known as posted), a fingerprint package will be sent to the applicant, as required by law. Please include your Application Fee Number in any correspondence. All correspondence should be sent to: Contractors State License Board 9821 Business Park Drive Sacramento, CA 95827-1703 Mailing Address: P.O. Box 26000, Sacramento, CA 95826-0026 Please detach this General Information section before submitting the completed application package to CSLB. 13A-1 (rev. 06/11) General Information Page 4 of 4

CONTRACTORS STATE LICENSE BOARD

9821 Business Park Drive, Sacramento, CA 95827 Mailing Address: P.O. Box 26000, Sacramento, CA 95826 800-321-CSLB (2752) | www.cslb.ca.gov | CheckTheLicenseFirst.com

STATE OF CALIFORNIA Governor Edmund G. Brown Jr.

FOR CSLB USE ONLY

Application for Original Contractor License

Application Fees Single classification.................................$300. Initial license fee (to be paid after exam) .$180. Total fees required for original license .......$480.
The application fee for a single classification ($300) is not refundable once the application has been filed. Attach a money order or a personal, business, certified, or cashiers check made payable to the Registrar of Contractors. Do not send cash. There is a $10 service charge for each dishonored check.

Voluntary contribution to Construction Management Education Account ..........$______

Please type or print neatly and legibly in black or dark blue ink. SECTION 1 BUSINESS NAME AND ADDRESS
Business Name: The legal business name is the name that will appear on the license and is the actual name under which the contracting business will
operate. The full business name must be provided. Name Compatibility: The business name must be compatible with the license classification and the business entity. For example, it would not be acceptable for ABC123 Tile to apply for a C-10 Electrical contractor license, but it would be acceptable for ABC123 Construction to apply for a B-General Building contractor license or for ABC123 Tile to apply for a C-54 Ceramic and Mosaic Tile contractor license. In addition, it would not be acceptable for a sole ownership to use the words partners or corporation in its business name.
1. FULL NEW BUSINESS NAME 2. CLASSIFICATION REQUESTED (Only one classification may be requested on the original application if an exam is required ) City State ZIP Code

3a. BUSINESS MAILING ADDRESS Number/Street or P.O. Box

3b. BUSINESS STREET ADDRESS Number/Street Only NO P.O. Boxes or PMBs

City

State

ZIP Code

3c. BUSINESS PHONE NUMBER

BUSINESS FAX NUMBER

BUSINESS EMAIL ADDRESS

SECTION 2 BUSINESS ENTITY

Corporation / Partnership: Corporations must provide a current and active California Secretary of State corporate registration number below. Please be sure to write the corporate titles (president, secretary, and treasurer) in the space provided for the appropriate personnel in Sections 3 and 4. Partnerships must list their Federal Employer Identification Number (FEIN) below (personal Social Security numbers are not acceptable). (See pages 2 and 3 of the General Information section for more information.)
4. NEW BUSINESS WILL OPERATE AS A (check only one)

Sole Ownership

Partnership Federal Employer ID # _____________________

California Corporation # _____________________

SECTION 3 QUALIFYING INDIVIDUAL FULL LEGAL NAME AND ADDRESS

Qualifying Individual (Qualifier): A qualifying individual is required for every classification on every license issued by CSLB. You must provide full
legal names of all individuals. (See page 1 of the General Information section for more information.)
5a. QUALIFIERS FULL LEGAL NAME Last First Middle DATE OF BIRTH SOCIAL SECURITY NUMBER

5b. RESIDENCE ADDRESS Number/Street Only NO P.O. Boxes or PMBs

City

State

ZIP Code

6. QUALIFIERS EXISTING / PREVIOUS CSLB LICENSE NUMBER(S) (If none, enter N/A)

PERCENTAGE OF NEW BUSINESS OWNED BY THE QUALIFIER

DRIVER LICENSE NUMBER

RESIDENCE PHONE NUMBER

______%
Owner Qualifying Partner RME* RMO/Corporate Officer - Title(s)

7. TITLE OR POSITION (check only one) Corporate titles president, secretary, and treasurer for California corporations; president only for foreign corporations

* RMEs are prohibited from having an active sole owner license. Please visit CSLBs website for an Application to Inactivate Contractors License, if needed.
8. THE EXAMINATIONS ARE ADMINISTERED IN ENGLISH. IF YOU WILL REQUIRE THE USE OF A TRANSLATOR, PLEASE CHECK THIS BOX.

I certify under penalty of perjury under the laws of the State of California that all statements, answers, and representations made in this application, including all supplementary statements attached hereto, are true and accurate, and that I have reviewed the entire contents of this application. (The definition of perjury is telling a lie while under oath.) I authorize the Franchise Tax Board to provide CSLB with required tax information pursuant to B&P Code Section 7145.5.
Date Signature Printed Name

FOR CSLB USE ONLY

*APP-EXAM*
13A-1 (rev. 06/11)

Application Page 1 of 3

SECTION 4 PERSONNEL FULL LEGAL NAMES AND ADDRESSES (Other than Qualifying Individual)
The following must be completed by all individuals who will be listed on the license. You must provide full legal names of all individuals. Each individual must sign the certification under penalty of perjury. (The definition of perjury is telling a lie while under oath.)
9a. PERSONNEL FULL LEGAL NAME Last First Middle DATE OF BIRTH SOCIAL SECURITY NUMBER

RESIDENCE ADDRESS Number/Street Only NO P.O. Boxes or PMBs

City

State

ZIP Code

DRIVER LICENSE #

TITLE OR POSITION (check only one)

RESIDENCE PHONE NUMBER

Owner

General Partner

Limited Partner

Corporate Officer - Title(s)

I certify under penalty of perjury under the laws of the State of California that all statements, answers, and representations made in this application, including all supplementary statements attached hereto, are true and accurate, and that I have reviewed the entire contents of this application. I authorize the Franchise Tax Board to provide CSLB with required tax information pursuant to B&P Code Section 7145.5.
Date Signature Printed Name

9b. PERSONNEL FULL LEGAL NAME Last

First

Middle

DATE OF BIRTH

SOCIAL SECURITY NUMBER

RESIDENCE ADDRESS Number/Street Only NO P.O. Boxes or PMBs

City

State

ZIP Code

DRIVER LICENSE #

TITLE OR POSITION (check only one)

RESIDENCE PHONE NUMBER

General Partner

Limited Partner

Corporate Officer - Title(s)

I certify under penalty of perjury under the laws of the State of California that all statements, answers, and representations made in this application, including all supplementary statements attached hereto, are true and accurate, and that I have reviewed the entire contents of this application. I authorize the Franchise Tax Board to provide CSLB with required tax information pursuant to B&P Code Section 7145.5.
Date Signature Printed Name

9c. PERSONNEL FULL LEGAL NAME Last

First

Middle

DATE OF BIRTH

SOCIAL SECURITY NUMBER

RESIDENCE ADDRESS Number/Street Only NO P.O. Boxes or PMBs

City

State

ZIP Code

DRIVER LICENSE #

TITLE OR POSITION (check only one)

RESIDENCE PHONE NUMBER

General Partner

Limited Partner

Corporate Officer - Title(s)

I certify under penalty of perjury under the laws of the State of California that all statements, answers, and representations made in this application, including all supplementary statements attached hereto, are true and accurate, and that I have reviewed the entire contents of this application. I authorize the Franchise Tax Board to provide CSLB with required tax information pursuant to B&P Code Section 7145.5.
Date Signature Printed Name

9d. PERSONNEL FULL LEGAL NAME Last

First

Middle

DATE OF BIRTH

SOCIAL SECURITY NUMBER

RESIDENCE ADDRESS Number/Street Only NO P.O. Boxes or PMBs

City

State

ZIP Code

DRIVER LICENSE #

TITLE OR POSITION (check only one)

RESIDENCE PHONE NUMBER

General Partner

Limited Partner

Corporate Officer - Title(s)

I certify under penalty of perjury under the laws of the State of California that all statements, answers, and representations made in this application, including all supplementary statements attached hereto, are true and accurate, and that I have reviewed the entire contents of this application. I authorize the Franchise Tax Board to provide CSLB with required tax information pursuant to B&P Code Section 7145.5.
Date Signature Printed Name

(If additional space is needed, please make a copy of this blank page.)

FOR CSLB USE ONLY

13A-1d (rev. 06/11)

Application Page 2 of 3

SECTION 5 REQUIRED APPLICATION QUESTIONS

All questions in this section must be answered. Questions 10, 11, and 12 pertain to all individuals listed on this application (qualifying individual and all personnel listed in Section 4). If you checked Yes in response to any question, the person involved must attach a separate sheet with a detailed explanation for each situation.
10. To the best of your knowledge, is anyone listed on this application (or any company the person is or was a part of, or any immediate family member of the applicant) named in or responsible for any entered and unsatisfied judgments, liens, and/or claims against any bond or cash deposit pertaining to a construction project? (Immediate family member is defined by B&P Code Section 7075.1 as a spouse, father, mother, brother, sister, son, daughter, stepson, stepdaughter, grandson, granddaughter, son-in-law, or daughter-in-law.) If you checked Yes for this question, you are required to attach a statement identifying all judgments (pending or on record), liens, past due unpaid bills, claims, or suits and a detailed explanation of the situation. Include the names and addresses of the parties involved. If the obligation was or is being discharged in bankruptcy, attach a copy of the bankruptcy filing and a copy of the creditors list. 11. Has anyone listed on this application ever pleaded guilty or no contest to or been convicted by a court of any misdemeanor or felony in this state or elsewhere? You are required to check Yes and provide all of the requested information even if the conviction was sealed or expunged under Penal Code Section 1203.4 or an applicable code of another state. If you checked Yes for this question, you are required to attach a statement disclosing all pleas/convictions, including violated law sections, and thoroughly explain the acts or circumstances which resulted in the plea/conviction. In addition, the following information must be included for each plea/conviction: date of the plea/conviction, county and state where the violation took place, name of the court, court case number, sentence imposed, jail/prison term served, terms and conditions of parole or probation, parole or probation completion dates, and parole agent/probation officer names and phone numbers. You may submit the required information using the Disclosure Statement Regarding Criminal Plea/Conviction form
that is available on the Forms and Applications page on CSLBs website.
The information provided will be verified through CSLBs fingerprinting requirement. Failure to report a
plea/conviction is considered falsification of your application and is grounds for denial of your application.
12. To the best of your knowledge, has anyone on this application (or any company the person was a part of, or any immediate family member of the applicant) ever received a citation from the Contractors State License Board or had a contractor license or other professional or vocational license or registration denied, suspended, or revoked by this state or elsewhere? (Check No if the license was suspended due to lack of a bond, workers compensation, a qualifier, or family support.) If you checked Yes for this question, you are required to attach a statement detailing the events leading to this action. 13. (This question must be answered by the qualifying individual.) The Registrar of Contractors has determined that direct supervision and control includes any one or a combination of the following activities: supervising construction, managing construction activities by making technical and administrative decisions, checking jobs for proper workmanship, or direct supervision on construction job sites. Will you, as the qualifying individual, perform one or more of these duties? 14. (This question must be answered only if the qualifying individual is a Responsible Managing Employee [RME].) CCR Section 823 states that an RME must work at least 32 hours per week or 80% of the total operating hours per week for the entity for which he or she acts as the qualifier. Will you, as the Responsible Managing Employee, meet the requirement of CCR Section 823 cited above? 15. By law, all new businesses applying for a license must have more than $2,500 operating capital. (B&P Code Section 7067.5)
Operating capital is your current assets minus your current liabilities. Does your operating capital exceed $2,500?

Yes

No

Yes

No

Yes

No

Yes Yes Yes

No No No

SECTION 6 QUALIFYING INDIVIDUAL EDUCATION, APPRENTICESHIP, AND LICENSURE

16. HAVE YOU COMPLETED AN EDUCATIONAL OR APPRENTICESHIP PROGRAM?

Yes

No

IF YOU CHECKED YES FOR THIS QUESTION, YOU MAY BE GRANTED CREDIT FOR COMPLETED EDUCATION IF YOU: Submit a copy of your diploma for a four-year degree in a business or construction-related field; OR Submit transcripts for a two-year degree (or less), technical training (must include course hours and descriptions), and all other degrees. Transcripts must be official and contained in a sealed envelope. (If you received your degree outside the United States, your transcripts must be translated and evaluated by an accredited evaluation service that does business within the United States.) YOU MAY BE GRANTED CREDIT FOR A COMPLETED APPRENTICESHIP PROGRAM IF YOU: Submit a copy of your apprenticeship certificate; AND Enter the beginning and ending dates of your completed apprenticeship program: From___________________ to ___________________ (The apprenticeship period cannot overlap the journeyman level experience period being certified.) Month/Day/Year Month/Day/Year

FOR CSLB USE ONLY

13A-1 (rev. 06/11)

Application Page 3 of 3

CONTRACTORS STATE LICENSE BOARD

9821 Business Park Drive, Sacramento, CA 95827 Mailing Address: P.O. Box 26000, Sacramento, CA 95826 800.321.CSLB (2752) | www.cslb.ca.gov | CheckTheLicenseFirst.com

STATE OF CALIFORNIA Governor Edmund G. Brown Jr.

CERTIFICATION OF WORK EXPERIENCE General Information

This form must be filled in completely in order to document work experience or the application will be returned. The qualifying individual and certifier must type or print neatly and legibly in black or dark blue ink pencil is not acceptable. FORMS CONTAINING STRIKEOUTS OR MODIFICATIONS MAY BE REJECTED. Corrections on the Certification of Work Experience forms must be initialed by the certifier. Original signatures are required faxed, photocopied, or stamped signatures are not acceptable. All qualifying individuals and certifiers must be at least 18 years old. All Certification of Work Experience forms must be submitted with the application. The Certification of Work Experience form, when filed with an application, becomes the property of CSLB and is kept as a matter of record. Make a copy of the completed and signed form for your records you may be asked to provide further documentation or testimony to verify your experience. If, within the last five (5) years, you have passed an examination in the classification for which you are now applying, you may not need to complete this form. Such applicants should complete the Application for Original Contractor License Examination Waiver (7065). However, if you are applying for a waiver of the examination pursuant to B&P Code Sections 7065.1(b) or 7065.1(c), you do need to complete this form. (Please refer to Blueprint for Becoming a Licensed Contractor for more information on exam waivers.) NOTE: If your previous application was denied on the basis of a lack of qualifying work experience, you must complete this form, regardless of whether or not you passed the exam. Anyone who knowingly obtains or offers false or forged documents to be filed, registered, or recorded in any public office in California is guilty of a felony. (Penal Code Section 115)

PART 1 QUALIFYING INDIVIDUAL INFORMATION

The qualifying individual must complete Part 1 in its entirety before the certifier completes Part 2.

PART 2 WORK EXPERIENCE AND CERTIFICATION STATEMENT

The certifier must complete Part 2 in its entirety after the qualifying individual has completed Part 1. The qualifying individual must document at least four (4) full years of journeyman-level or higher experience in the classification for which he or she is applying. The experience must have been obtained within the last 10 years. The qualifying individuals work experience must have been completed at the level of journeyman, foreman, supervisor, or contractor, or as an owner-builder or self-employed individual, as defined below: A journeyman is an experienced worker who is fully qualified (as opposed to a trainee, helper, laborer, assistant, apprentice, etc.) and is able to perform the trade without supervision, or a person who has completed an apprenticeship program. (CCR Section 825) A foreman or supervisor is a person who has the knowledge and skills of a journeyman and directly supervises construction projects. A contractor is an individual who is currently a licensed California contractor, a former licensed California contractor, personnel of record on a California license, or an out-of-state licensed contractor. A contractor has the skills necessary to manage the daily activities of a construction business, including field supervision. An owner-builder (a person who performs work solely on his or her own properties) or a self-employed individual must have the knowledge and skills of a journeyman as listed above and the skills necessary to manage the daily activities of a construction business, including field observation. Owner-builders must complete and submit the Construction Project Experience form. The Description of Classifications document may be used as a reference only and is available through a link on the home page of CSLBs website. You should not copy directly from the document when listing the specific trade duties the qualifying individual performed or supervised in the classification for which he or she is applying. The Certification Statement at the bottom of the form must be completed by a qualified, responsible person who is able to certify the work experience of the qualifier. The certifier can be an employer, fellow employee, journeyman, union representative, contractor, business associate, or a client if the applicant is/was self-employed. This form will help CSLB determine whether the qualifier has the experience necessary to become a capable, qualified contractor. The certifier must have direct knowledge of the qualifiers experience during the time period listed. Direct knowledge means personal knowledge of the experience that does not depend on outside information or hearsay. The certifier must be able to certify that the qualifier demonstrated a level of knowledge and skills expected of a journeyman or higher in the classification for which he or she is applying. Any licensee whose signature appears on a falsified Certification of Work Experience form, or who otherwise certifies false or misleading experience claims submitted by an applicant to obtain a contractor license, will be subject to disciplinary action. (B&P Code Section 7114.1)

13A-11 (rev. 06/11)

Certification of Work Experience Page 1 of 2

CONTRACTORS STATE LICENSE BOARD

9821 Business Park Drive, Sacramento, CA 95827 Mailing Address: P.O. Box 26000, Sacramento, CA 95826 800.321.CSLB (2752) | www.cslb.ca.gov | CheckTheLicenseFirst.com

STATE OF CALIFORNIA Governor Edmund G. Brown Jr.

Certification of Work Experience

Please read the General Information section on the previous page before beginning. The qualifying individual must complete the information in Part 1; the individual certifying the experience (certifier) must complete Part 2. The experience must be verifiable through payroll records or similar documents. If additional space is needed to list the trade duties, please attach a separate sheet. Use a separate form for each employer. If you need additional forms, please make a copy of this blank form or visit CSLBs website. Please type or print neatly and legibly in black or dark blue ink. FORMS CONTAINING STRIKEOUTS OR MODIFICATIONS MAY NOT BE ACCEPTED. Corrections on the Certification of Work Experience forms must be initialed by the certifier.

PART 1 QUALIFYING INDIVIDUAL INFORMATION

The qualifying individual must complete Part 1 in its entirety.
1. QUALIFIERS FULL LEGAL NAME Last First Middle

2. BUSINESS NAME OF EMPLOYER OR, IF YOU WERE SELF-EMPLOYED, LEAVE THIS SPACE BLANK AND (If you checked the box, skip line 3 and go to line 4 ) CHECK THIS BOX

LICENSE NUMBER OF EMPLOYER

3. EMPLOYERS BUSINESS STREET ADDRESS Number/Street Only NO P.O. Boxes

City

State

ZIP Code

4. WAS THE EXPERIENCE OBTAINED WORKING ON YOUR OWN PROPERTY AS AN OWNER-BUILDER (see previous page for definition)? Yes No IF YOU CHECKED YES ABOVE, USE THE ENCLOSED CONSTRUCTION PROJECT EXPERIENCE FORM TO PROVIDE A LIST OF COMPLETED PROJECTS.

PART 2 WORK EXPERIENCE AND CERTIFICATION STATEMENT

The certifier must complete Part 2 in its entirety after the qualifying individual has completed Part 1.
5. APPLICANTS JOURNEYMANLEVEL OR HIGHER
TIME-BASE WORKED WAS (check one):

FULL-TIME PART-TIME

FOR A TOTAL OF

FROM_________________ TO _________________
Month/Day/Year Month/Day/Year

______________ YEAR(S) and ______________ MONTH(S)

(Do not claim credit for full-time work if applicant worked (LIST ONLY JOURNEYMAN-LEVEL OR HIGHER EXPERIENCE only part-time. For example, if applicant worked half-time THAT WAS OBTAINED IN THE APPLICABLE CLASSIFICATION) for six (6) years, write 3 years in the space above )

6. IN THE SPACE BELOW, LIST ALL SPECIFIC TRADE DUTIES APPLICANT PERFORMED OR SUPERVISED IN THE CLASSIFICATION FOR WHICH HE/SHE IS APPLYING. PLEASE REFER TO THE DESCRIPTION OF CLASSIFICATIONS DOCUMENT FOR ASSISTANCE. (Do not list office work or individual project names )

My relationship to ____________________________________________________________________________________________ is or was (check all that apply):

Name of Qualifying Individual (Applicant)

Employer Union Representative

PHONE NUMBER

Fellow Employee Foreman or Supervisor Journeyman Business Associate Contractor (License Number__________________________) Client (if qualifier was self-employed)
City EMAIL ADDRESS State ZIP Code FAX NUMBER

CERTIFIERS STREET ADDRESS Number/Street Only NO P.O. Boxes

(
7. Date

)
Signature

)
Printed Name

I certify that I have direct knowledge of the work covering the time period outlined above. I certify under penalty of perjury, under the laws of the State of California, that the information stated above is true and correct. (The definition of perjury is telling a lie while under oath )

Note:

For information on the collection of personal information, please refer to the General Information section at the beginning of this application package, under the heading Collection of Personal Information.

FOR CSLB USE ONLY

*ADDL-cert*
13A-11 (rev. 06/11)

Certification of Work Experience Page 2 of 2

CONTRACTORS STATE LICENSE BOARD

9821 Business Park Drive, Sacramento, CA 95827 Mailing Address: P.O. Box 26000, Sacramento, CA 95826 800.321.CSLB (2752) | www.cslb.ca.gov | CheckTheLicenseFirst.com

STATE OF CALIFORNIA Governor Edmund G. Brown Jr.

Construction Project Experience

This form must be completed ONLY if the qualifying individual indicates on the Certification of Work Experience form that he or she obtained experience working on his or her own property as an owner-builder, or as otherwise requested by CSLB. Use a separate form for each project. If you need additional forms, please make a copy of this blank form or visit CSLBs website. Please type or print neatly and legibly in black or dark blue ink. Incomplete forms are not accepted.
1. QUALIFIERS (OWNER-BUILDER) FULL LEGAL NAME Last First Middle PHONE NUMBER

(
2. PROJECT STREET ADDRESS Number/Street Only NO P.O. Boxes City

)
State ZIP Code

3. START DATE Month/Day/Year

COMPLETION DATE Month/Day/Year

TOTAL PROJECT TIME ____________ YEARS and ____________ MONTHS

4. TYPE OF PROJECT (For example: residential room addition) 5. TRADES PERFORMED (For example: framing, electrical) 6. PROJECT SIZE (square feet, linear feet, or cubic yards) Building Other

7. YOUR DUTIES AND WORK YOU PERFORMED (For example: prepared plans, obtained permits, installed all sheetrock, installed 4-ton HVAC unit)

8. YOUR POSITION LEVEL (For example: trainee, apprentice, journeyman, supervisor) 9. EXPLAIN HOW PAST EXPERIENCE, TRAINING, AND/OR EDUCATION PREPARED YOU FOR THE POSITION AT THE LEVEL STATED IN #8 ABOVE

10. SCOPE OF WORK (For example: placed 600 sf of mix & sod, installed 2500 sf of concrete tile roof, poured 12 yds of concrete drive, installed 20 linear ft. of cabinetry)

11. NUMBER OF LABORERS AND THE TRADES THEY PERFORMED

12. NUMBER OF GENERAL CONTRACTORS OR SUBCONTRACTORS AND THE TRADES THEY PERFORMED

13. COST OF MATERIALS OR TOTAL COST OF PROJECT

FOR CSLB USE ONLY

*project-LIST*
13A-64 (rev. 06/11)

Construction Project Experience