Calimesa, CA · Riverside County
Licensed Contractor Attestation as to Exempt Status
Licensed contractors complete this attestation to claim exempt status from maintaining workers’ compensation insurance for work covered by permits they apply for.
What this form is
This attestation lets a licensed contractor state that they have a California State License Board document on file certifying they perform all work described in their permit applications. It also states that the contractor does not intend to employ or subcontract the work to others. The form asks for the contractor’s business name, license classification and number, signature, date, and printed name.
Who needs it
A licensed contractor seeking exempt status from maintaining workers’ compensation insurance for work covered by Calimesa permit applications needs this attestation.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This attestation is signed and dated without a notary; the signer simply provides their printed name.
How to submit this form
- 1
Download the Attestation
Download the Licensed Contractor Attestation as to Exempt Status PDF.
- 2
Complete the Contractor Information
Enter your business name, CSLB license classification and number, then provide your signature, date, and printed name.
- 3
Gather Subcontractor Information if Needed
If you ask to add a subcontractor to your permit application, provide that contractor’s license and insurance information to the city.
- 4
Submit to the City
Submit the completed attestation to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- What does the Licensed Contractor Attestation as to Exempt Status do?
- It lets a licensed contractor attest that they have a document on file with the California State License Board and do not intend to employ or subcontract the permit work.
- Who completes this attestation?
- A licensed contractor seeking exempt status from maintaining workers’ compensation insurance for work described in permit applications completes the attestation.
- Do I need a notary for this attestation?
- No. The document is signed and dated without a notary; the signer provides their printed name.
- How do I submit this attestation?
- The document does not give submission instructions. Submit it to the city department named on the form and check the city website for current contact details.
Need something notarized?
This Licensed Contractor Attestation as to Exempt Status doesn’t need a notary — but if you have another Calimesa form that does, a commissioned online notary can help.