D & P Engineering/Demo 78-182 La Fonda 12CONTRACT
THIS CONTRACT, by and between the CITY OF LA QUINTA, a municipal
corporation, herein referred to as "City," and D&P Engineering herein referred to as
"Contractor."
WITNESSETH:
In consideration of their mutual covenants, the parties hereto agree as follows:
1 . Contractor shall furnish all necessary labor, material, equipment, transportation and
services for demolition, removal and disposal of the entire four (4) unit structure, with
option to pump, collapse and fill septic system if found at 78-182 Avenida La Fonda in the
City of La Quinta, California pursuant to the attached proposal listed as Exhibit A.
2. Contractor will comply with all Federal, State, County, and La Quinta Municipal
Code, which are, as amended from time to time, incorporated herein by reference.
3. All work shall be done in a manner satisfactory to the Director of Building and
Safety.
4. Contractor shall commence work after the issuance of a written Notice to Proceed
and agrees to have all work completed within 30 days from the date of Notification to
Proceed.
5. In consideration of said work, City agrees to pay Contractor such sums as shall be
approved by the Director of Building and Safety at lump sums and/or unit prices stated in
the Contractor's Bid, the base consideration of Twelve Thousand Five Hundred Dollars and
Zero Cents ($12,500.00) and not to exceed Thirteen Thousand Dollars and Zero Cents
($13,000.00) with inclusion of option. All payments shall be subject to approval by the
Director of Building and Safety.
6. Prevailing Wage is not required for this project.
7. Except for the gross negligence or willful misconduct of an Indemnified Party (as
hereinafter defined), the Contractor hereby assumes liability for and agrees to defend (at
Indemnified Parties' option), indemnify, protect and hold harmless City and its Project
Consultants, and Engineers, officers, agents, and employees ("Indemnified Parties") from
and against any and all claims, charges, damages, demands, actions, proceedings, losses,
stop notices, costs, expenses (including counsel fees), judgments, civil fines and penalties,
liabilities of any kind or nature whatsoever, which may be sustained or suffered by or
secured against the Indemnified Parties arising out of or encountered in connection with
this Contract or the performance of the Work including, but not limited to, death of or
bodily or personal injury to persons or damage to property, including property owned by or
under the care and custody of City, and for civil fines and penalties, that may arise from or
be caused, in whole or in part, by any negligent or other act or omission of Contractor, its
Revised: 4-6-11
officers, agents, employees or Subcontractors including, but not limited to, liability arising
from:
a. Any dangerous, hazardous, unsafe or defective condition of, in or on the
premises, of any nature whatsoever, which may exist by reason of any act,
omission, neglect, or any use or occupation of the premises by Contractor,
its officers, agents, employees, or subcontractors;
b. Any operation conducted upon or any use or occupation of the premises by
Contractor, its officers, agents, employees, or subcontractors under or
pursuant to the provisions of this contract or otherwise;
c. Any act, omission or negligence of Contractor, its officers, agents,
employees, or Subcontractors;
d. Any failure of Contractor, its officers, agents or employees to comply with
any of the terms or conditions of this Contract or any applicable federal,
state, regional, or municipal law, ordinance, rule or regulation; and
e. The conditions, operations, uses, occupations, acts, omissions or negligence
referred to in Sub -subsections (1), (2), (3), and (4), existing or conducted
upon or arising from the use or occupation by Contractor on any other
premises in the care, custody and control of City.
The Contractor also agrees to indemnify City and pay for all damages or loss suffered by
City including but not limited to damage to or loss of City property, to the extent not
insured by City and loss of City revenue from any source, caused by or arising out of the
conditions, operations, uses, occupations, acts, omissions or negligence referred to in Sub -
subsections (a), (b), (c), (d) and (e).
Contractor's obligations under this Section apply regardless of whether or not such claim,
charge, damage, demand, action, proceeding, loss, stop notice, cost expense, judgment,
civil fine or penalty, or liability was caused in part or contributed to by an Indemnified
Party. However, without affecting the rights of City under any provision of this contract,
Contractor shall not be required to indemnify and hold harmless City for liability attributable
to the active negligence of City, provided such active negligence is determined by
agreement between the parties or by the findings of a court of competent jurisdiction. In
instances where City is shown to have been actively negligent and where City's active
negligence accounts for only a percentage of the liability involved, the obligation of
Contractor will be for that entire portion or percentage of liability not attributable to the
active negligence of City.
Contractor agrees to obtain executed indemnity agreements with provisions identical to
those set forth here in this section from each and every subcontractor or any other person
or entity involved by, for, with or on behalf of Contractor in the performance of this
contract. In the event Contractor fails to obtain such indemnity obligations from others as
required here, Contractor agrees to be fully responsible according to the terms of this
section.
Failure of
City to monitor
compliance
with these requirements imposes no additional
obligations
on City and will
in no way
act as a waiver of any rights hereunder. This
obligation
to indemnify and
defend City
as set forth here is binding on the successors,
Revised, 4-6-11
assigns or heirs of Contractor and shall survive the termination of this contract or this
section.
This indemnity shall survive termination of the Contract or Final Payment hereunder. This
Indemnity is in addition to any other rights or remedies that the Indemnified Parties may
have under the law or under any other Contract Documents or Agreements. In the event
of any claim or demand made against any party which is entitled to be indemnified
hereunder, City may, in its sole discretion, reserve, retain or apply any monies to the
Contractor under this Contract for the purpose of resolving such claims; provided,
however, City may release such funds if the Contractor provides City with reasonable
assurance of protection of the Indemnified Parties' interests. City shall, in its sole
discretion, determine whether such assurances are reasonable.
The City will not be liable for any accident, loss, or damage to the work prior to its
completion and acceptance.
8. Except as otherwise required, Contractor shall concurrently with the execution of
this contract, furnish the City satisfactory evidence of insurance of the kinds and in
the amounts as follows:
Commercial General Liability Policy
Commercial General Liability Insurance using Insurance Services Office "Commercial
General Liability" policy form CG 00 01 or the equivalent. Defense costs must be
paid in addition to limits. There shall be no cross liability exclusion for claims or
suits by one insured against another. Limits shall be no less than One Million
Dollars ($1,000,000) per occurrence for all covered losses and no less than Two
Million Dollars ($2,000,000) general aggregate.
Contractor's policy shall contain no endorsements limiting coverage beyond the
basic policy coverage grant for any of the following:
a. Explosion, Collapse or Underground Hazard(X CU).
b. Products and Completed Operations.
c. Pollution liability.
d. Contractual liability.
Coverage shall be applicable to City for injury to employees of: contractors,
subcontractors or others involved in the project. Policy shall be endorsed to provide
a separate limit applicable to this project.
Revised: 4-6-7 f
Workers' Compensation Insurance
Workers' Compensation on a state -approved policy form providing statutory
benefits as required by law with employer's liability limits no less than $1,000,000
per accident for all covered losses.
Business Auto Policy
Business Auto Coverage on ISO Business Auto Coverage form CA 00 01 06 92
including symbol 1 (Any Auto) or the exact equivalent. Limits shall be no less than
$1,000,000 per accident, combined single limit. If Contractor owns no vehicles,
this requirement may be satisfied by a non -owned auto endorsement to the general
liability policy described above.
Excess or Umbrella Liability Insurance
Excess or Umbrella Liability Insurance (Over Primary) if used to meet limit
requirements, shall provide coverage at least as broad as specified for the
underlying coverage. Any such coverage provided under an umbrella liability policy
shall include a drop down provisions providing primary coverage for liability not
covered by primary but covered by the umbrella. Self -insured retentions are not
permitted. Coverage shall be provided on a "pay on behalf' basis, with defense
costs payable in addition to policy limits. There shall be no cross liability exclusion
precluding coverage for claims or suits by one insured against another. Coverage
shall be applicable to City for injury to employees of Contractor, subcontractors or
others involved in the Work. The scope of coverage provided is subject to approval
of City following receipt of proof of insurance as required herein. Limits are subject
to review but in no event less than $1,000,000 per occurrence and aggregate.
This insurance shall be kept in full force and effect by Contractor during this entire contract
and all premiums thereon shall be promptly paid by it. Each policy shall further state that it
cannot be canceled without written notice to the City and shall name the City as an
additional insured. Failure to maintain the required amounts and types of coverage
throughout the duration of this Contract shall constitute a material breach of this Contract.
a. Contractor agrees to endorse the third party general liability coverage required
herein to include as additional insureds City, its officials, employees and agents,
using standard ISO endorsement No. CG 2010 with an edition date of 1985 or
equivalent. Contractor also agrees to require all contractors, subcontractors, and
anyone else involved in any way with the project contemplated by this Contract to
do likewise.
b. Any waiver of subrogation express or implied on the part of City to any party
involved in this Contract or related documents applies only to the extent of
insurance proceeds actually paid. City, having required that it be named as an
additional insured to all insurance coverage required herein, expressly retains the
right to subrogate against any party for sums not paid by insurance. For its part,
Contractor agrees to waive subrogation rights against City regardless of the
Revised: 4-6-1r
applicability of any insurance proceeds, and to require all contractors,
subcontractors or others involved in any way with the project(s) contemplated by
this Contract, to do likewise.
c. All insurance coverage maintained or procured by Contractor or required of others
by Contractor pursuant to this Contract shall be endorsed to delete the subrogation
condition as to City, or to specifically allow Contractors or others providing
insurance herein to waive subrogation prior to a loss. This endorsement shall be
obtained regardless of existing policy wording that may appear to allow such
waivers.
d. It is agreed by Contractor and City that insurance provided pursuant to these
requirements is not intended by any party to be limited to providing coverage for the
vicarious liability of City, or to the supervisory role, if any, of City. All insurance
coverage provided pursuant to this or any other Contract (express or implied) in any
way relating to City is intended to apply to the full extent of the policies involved.
Nothing referred to here or contained in any Contract involving City in relation to
the project(s) contemplated by this Contract is intended to be construed to limit the
application of insurance coverage in any way.
e. None of the coverages required herein will be in compliance with these requirements
if they include any limiting endorsement of any kind that has not been first
submitted to City and approved of in writing.
f. All coverage types and limits required are subject to approval, modification and
additional requirements by the City, as the need arises. Contractor shall not make
any reductions in scope of coverage (e.g. elimination of contractual liability or
reduction of discovery period) that may affect City's protection without City's prior
written consent.
g. Proof of compliance with these insurance requirements, consisting of binders of
coverage, or endorsements, or certificates of insurance, at the option of City, shall
be delivered to City at or prior to the execution of this Contract. In the event such
proof of any insurance is not delivered as required, or in the event such insurance is
canceled at any time and no replacement coverage is provided, City has the right,
but not the duty, to obtain any insurance it deems necessary to protect its interests
under this or any other agreement and to pay the premium. Any premium so paid
by City shall be charged to and promptly paid by Contractor or deducted from sums
due Contractor, at City option.
h. Contractor agrees to endorse, and to require others to endorse, the insurance
provided pursuant to these requirements, to require written notice to City and the
appropriate tender prior to cancellation of such liability coverage and notice of any
material alteration of non -renewal of any such coverage, and to require contractors,
subcontractors, and any other party in any way involved with the project
contemplated by this Contract to do likewise.
Revised: 4-6-11
It is acknowledged by the parties of this Contract that all insurance coverage
required to be provided by Contractor or any subcontractor, is intended to apply
first and on a primary non-contributing basis in relation to any other insurance
available to the City.
Contractor agrees to ensure that subcontractors, and any other party involved with
the project that is brought onto or involved in the project by contractor, provide the
same minimum insurance coverage required of Contractor. Contractor agrees to
monitor and review all such coverage and assumes all responsibility for ensuring
that such coverage is provided in conformity with the requirements of this section.
Contractor agrees that upon request, all agreements with subcontractors and others
engaged in the project will be submitted to City for review.
k. Contractor agrees not to self -insure or to use any self -insured retentions or
deductibles on any portion of the insurance required herein and further agrees that it
will not allow any contractor, subcontractor, Architect, Engineer or other entity or
person in any way involved in the performance of work on the project contemplated
by this Contract to self -insure its obligations to City. If contractor's existing
coverage includes a deductible or self -insured retention, the deductible or self -
insured retention must be declared to the City. At that time the City shall review
options with the contractor, which may include reduction or elimination of the
deductible or self -insured retention, substitution of other coverage, or other
solutions.
I. The City reserves the right at any time during the term of the contract to change
the amounts and types of insurance required by giving the Contractor ninety (90)
days advance written notice of such change. If such change results in substantial
additional cost to the Contractor, the City will negotiate additional compensation
proportional to the increased benefit to City.
m. For purposes of applying insurance coverage only, all contracts pertaining to the
project will be deemed to be executed when finalized and any activity commences
in furtherance of performance under this Contract.
n. Contractor acknowledges and agrees that any actual or alleged failure on the part of
City to inform Contractor of non-compliance with any insurance requirement in no
way imposes any additional obligations on City nor does it waive any rights
hereunder in this or any other regard.
o. Contractor will renew the required coverage annually as long as City, or its
employees or agents face an exposure from operations of any type pursuant to this
Contract. This obligation applies whether or not the Contract is canceled or
terminated for any reason. The insurance shall include but not be limited to
products and completed operations and discontinued operations, where applicable.
Termination of this obligation is not effective until City executes a written
statement to that effect.
Revised: 4-6-7f
p. Contractor agrees to waive its statutory immunity under any workers' compensation
statute or similar statute, in relation to the city, and to require all subcontractors
and any other person or entity involved in the project contemplated by this Contract
to do likewise.
q. Requirements of specific coverage features are not intended as limitations on other
requirements or as a waiver of any coverage normally provided by any given policy.
Specific reference to a given coverage feature is for purposes of clarification only as
it pertains to a given issue, and is not intended by any party or insured to be all-
inclusive.
r. Any provision in any of the construction documents dealing with the insurance
coverage provided pursuant to these requirements is subordinate to and superseded
by the requirements contained herein. These insurance requirements are intended
to be separate and distinct from any other provision in this Contract and are
intended by the parties here to be interpreted as such.
s. All liability coverage provided according to these requirements must be endorsed to
provide a separate aggregate limit for the project that is the subject of this Contract
and evidencing products and completed operations coverage for not less than two
years after issuance of a final certificate of occupancy by all appropriate
government agencies or acceptance of the completed work by City.
t. Contractor agrees to be responsible for ensuring that no contract used by any party
involved in any way with the project reserves the right to charge City or Contractor
for the cost of additional insurance coverage required by this Contract. Any such
provisions are to be deleted with reference to City. It is not the intent of City to
reimburse any third party for the cost of complying with these requirements. There
shall be no recourse against City for payment of premiums or other amounts with
respect thereto.
u. Contractor agrees to obtain and provide to City a copy of Professional Liability
coverage for Architects or Engineers, if any are working on this project through
Contractor. City shall determine the liability limit.
9. In accepting this Contract, Contractor certifies that in the conduct of its business it
does not deny the right of any individual to seek, obtain and hold employment without
discrimination because of race, religious creed, color, national origin, ancestry, physical
handicap, medical condition, marital status, sex or age as provided in the California Fair
Employment Practice Act (Government Code Sections 12900, at seq.) Contractor agrees
that a finding by the State Fair Employment Practices Commission that Contractor has
engaged during the term of this Contract in any unlawful employment practice shall be
deemed a breach of this Contract and Contractor shall pay to City $1,607.00 liquidated
damages for each such breach committed under this contract.
10. This Contract shall not be assignable by Contractor without the written consent of
City.
Revised., 4-6-11
11. Contractor shall notify the Director of Building and Safety forthwith when the
Contract is deemed completed.
12. In accepting this Contract, Contractor certifies that no member or officer of the firm
or corporation is an officer or employee of the City except to the extent permitted by law.
13. Contractor certifies that it is the holder of any necessary California State
Contractor's License and authorized to undertake the above work.
14. The City, or its authorized auditors or representatives, shall have access to and the
right to audit and reproduce any of the Contractor records to the extent the City deems
necessary to insure it is receiving all money to which it is entitled under the contract
and/or is paying only the amounts to which Contractor is properly entitled under the
Contract or for other purposes relating to the Contract.
15. The Contractor shall maintain and preserve all such records for a period of at least
three years after termination of the contract.
16. The Contractor shall maintain all such records in the City of La Quinta. If not, the
Contractor shall, upon request, promptly deliver the records to the City or reimburse the
City for all reasonable and extra costs incurred in conducting the audit at a location other
than at City offices including, but not limited to, such additional (out of the City) expenses
for personnel, salaries, private auditors, travel, lodging, meals and overhead.
IN WITNESS WHEREOF, the parties have executed this Agreement as of the dates stated
below.
"CITY"
CITY OF LA QUINTA
a California municipal corporation
By: U�, L, „J -e—_
Mark Weiss, Interim City Manager
APPROVED AS TO FORM:
SIGNED IN COUNTERPART Dated:
City Attorney
"CONTRACTOR"
r j n (if corporation, affix seal)
Dated: 1 �/ I `� By:
Revised: 4-6-1 f
(� (Please print)
Title: l C� Oy n -P r'
Address: SV �,/ '/mile SF
M't
Revised: 4-6-f r
11. Contractor shall notify the Director of Building and Safety forthwith when the
Contract is deemed completed.
12. In accepting this Contract, Contractor certifies that no member or officer of the firm
or corporation is an officer or employee of the City except to the extent permitted by law.
13. Contractor certifies that it is the holder of any necessary California State
Contractor's License and authorized to undertake the above work.
14. The City, or its authorized auditors or representatives, shall have access to and the
right to audit and reproduce any of the Contractor records to the extent the City deems
necessary to insure it is receiving all money to which it is entitled under the contract
and/or is paying only the amounts to which Contractor is properly entitled under the
Contract or for other purposes relating to the Contract,
15. The Contractor shall maintain and preserve all such records for a period of at least
three years after termination of the contract.
16. The Contractor shall maintain all such records in the City of La Quinta. If not, the
Contractor shall, upon request, promptly deliver the records to the City or reimburse the
City for all reasonable and extra costs incurred in conducting the audit at a location other
than at City offices including, but not limited to, such additional (out of the City) expenses
for personnel, salaries, private auditors, travel, lodging, meals and overhead.
IN WITNESS WHEREOF, the parties have executed this Agreement as of the dates stated
below.
"CITY"
CITY OF LA QUINTA
a California municipal corporation
Dated: By:so W PiOO�JNMP�
Mark Weiss, Interim City Manager
Revlmd. 4-6•11
EXHIBIT A
Proposal
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Revised: 4-6-11
JOSE BORUNDA INSURANCE AGENCY
49255 GRAPEFRUIT BLVD SUITE 2
COACHELLA, CA 92236
760.39MI3
ANY
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DANIEL GU7IE1REZ DBA; D & P
52121 FILLMORE ST
THERMAL, CA, 92274
ANY AUro
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0919039
17.
TE OF LIABILITY INSURANCE
07/27/M12
THIS CERTIFICATION M ISSUED AS A MATTER OF INFORNAATJON
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELO V.
INSURERS AFFORDING COVERAGE NA10 #
INmmik LANDMASURMN ICOMPAi RANCEC '
�ERING iNStEtER 8: TITAN INSURANCE COMPANY
GRADING OF LAND SY FOLLOWING BLUEPRINT INST UCTIOL
CERTIFICATE HOLDER IS ALSO AN INSURED'"'
LOCATION
78182 LA FONDA AND 78153 MAIN ST IN LA QUINTA, CA 92253
SUBJECT TO ALL THE TERMS,
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POLICY NUMBEFZ; LBA146798 00 COMMERCIAL GENpZAL LIABILITY
CC20101001
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modt'res insurance provided under the following:
COMMERCIAL GENERAL LIASILI�Y COVERAGE PART
SCHEDULE
Name of Person or Organization:
City of La Quinta
78495 Calls Tampico
La Quinta, CA 92253
(If no entry appears above, information I equired to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.) I
A. Section 11— Who Is An Insured Is
include as an insured the person o
7
amended to (1) All work, including materials, parts or
organization
Shown in the Schedule, but only with
liability arising out of your ongoing operations
equipment furnished in connection wM
respect to such work, on the project (other than
formed for that insured.
per, service, maintenance or repairs) to be
B. With respect to the insurance affor
performed by or on behalf of the addi-
Jed to these tional insured(s) at the site of the cov-
additional insureds, the following
added;
exclusion is ered operations has been completed,
or
2 Exclusions
(2) That portion of'sour wodf'Out ofwhich
This insurance does not apply to
"bodily inju. the injury or damage arises has been
ry"or "property damage" occurring
after: Put to its intended use by any person or
organization other than another con-
tractor or subcontractor engaged in
Performing operations for a principal as
a part of the same project.
CG 20101001.
Q ISO Properties, Inc., 2000 Page 1 of 1
p
POLICY NUMBER: 1BA146798 im
THIS ENDORSEMENT
WAIVER OF
This endorsement modifies insurance
COMMERCIAL GENERAL LIABIL
Name of Person or Organization:
City of La Quinta
78495 Celle Tampico
La Quints, CA 92253
(If no entry appears above, informal
applicable to this endorsement)
The TRANSFER OF RIGHTS OF I
CIAL GENERAL LIABILITY CONDn
We waive any right of recovery we
Muse of payments we make for
under a contract with that person or
waiver applies only to the person or,
COMMIERCIAL GENERAL LIABILITY
CG 24 0410 93
THE POLICY. PLEASE READ IT CAREFULLY.
SFER OF RIGHTS OF RECOVERY
NST OTHERS TO US
under the following:
:RAGE PART
SCHEDULE
required to complete this endorsement will be shown in the Declarations as
VERY AGAINST OTHERS TO US Condition (Section IV — COMMER-
) is amended by the addition of the following:
have against the person or organization shown in the Schedule above
or damage arising out of your ongoing operations or 'Wur work' done
iZation and included In the "prOducts-oompleted operations hazard". This
nation Shown in the Schedule above.
CG 24 0410 93 Copyright! Insura nee Services Office, Inc., 1992 Page 1 of 1 0
CONTRACTORS STATE LICENSE BOARD STATE OF CALIFORNIA
9821 Business Park Drive, Sacramento, California 95827 Governor Edmund G. Brown Jr.
Mailing Address: P.O. Box 26000, Sacramento, CA 95826
800-321-CSLB (2752)
www.cslb.ca.gov • CheckiheLicenseFird corn
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 C39
Roofing classification are not eligible for exemption from workers' compensation.
is 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 forth in Section 3.
Please type or print neatly and legibly in black or dark blue Ink.
SECTION 1 — REQUIRED BUSINESS NAME AND ADDRESS
Business Name (as it currently appears on CSLB records)
License or Application Fee Number
0-,J P-nuinpefjntL
%S7,s9--
Buusiinneess Ad ss (number/st t or P.O. box)
City
Co�d7re,,/
/Maili
�1 ��
/1State
gZiip�
Business Street Address (number/street only — NO P.O. boxes)
City
State
Zip Code
Business Phone Number Business Fax Number Business E-mail Address
(V ) YN -7773 (760 ) 349 -.53 Y/ dhJ P P_ACAli o2l'ha 0 arAdfil. COVA
❑ Check this box if the address shown above is new. CSLB will update your license / application business address of record.
SECTION 2 — REQUIRED CHECK BOX
YOU MUST CHECK ONLY ONE OF THE BOXES BELOW.
do not employ anyone in the manner subject to the workers' compensation laws of California. OR
❑ I 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.)
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 forth 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 peifury"is telling a lie while under oath.)
FALSIFICATION OF ANY DOCUMENT IS GROUNDS FOR DISCIPLINARY ACTION.
//Date Signature of Contractor (O er, P err 3-Officer) Printed Name of Contractor (Owner, Partner, or Officer)
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NOTICE ON COLLECnON OF PERSONAL INFORMATION
CSLB collects the personal infamatien requested an this form as authorized by Business and Professions Cede Section W. CSLB uses this information to identity
and evaluate applicants for licensors, issue and renew licenses, and enforce licensing standards sot by law and Notation. Submission d the requested information
is mandatory. CSLB cannot consider Mis Exemption from Workers Compensation farm unless you provide all of the requested infommation. You may review the
records maintained! by CSLB Nat contain your personal information, as permittetl by the Information Practices Ad. CSLB makes every effort to protect the personal
information you provide us; however, it may be disclosed in response to a Public Records Ad request as allowed by the Information Practices Act; to another
government agency as required by state or federal law; cr in response We courtor administrative order, a subpoena, ore search warrant. This application contains
an applicant authorization for the Franchise Tax Board to disclose to CSLB any outstanding furel liabilities for the purpose of administedrg Business and
Professions Code section 7145.5. For more information on the Information Practices Act, visit the Office of Privacy Protection's websde at w Pmracy.ce gov.
11111111111111111111111111111111111111111111111111111 13LS0(rev.4111)
FOR CSLB USE ONLY