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DEPARTMENT OF COMMERCE OWNER/BUILDER CERTIFICATION Division of Occupational and and Professional Licensing AGREEMENT TO COMPLY WITH THE Bureau of Investigation CONSTRUCTION TRADES LICENSING ACT 160 E 300 S PO Box 146741 Salt Lake City UT 84114-6741 Building Departments: Email to [EMAIL REDACTED] Or Fax to [PHONE REDACTED], Attn: Jody Woolf [ ] New Residential Construction PERMIT [ ] Remodel or Addition by Owner Description of Remodel or Name of Owner/Builder: Current Address: City, State, Zip: LOCATION OF CONSTRUCTION SITE: Address: City, State Zip: Subdivision: Lot No. CERTIFICATION I, certify under penalty of perjury that the following statements are true and correct and are based upon my understanding of the Utah Construction Trades Licensing Act: 1. For New Residential Construction Only. I am the sole owner of the property and construction project at the above described location; the project described is the only residential structure I have built this year; I have not built more than three residential structures in the past five years. For New Residential and Remodel Construction: 2. The improvements being placed on the property are intended to be used and will be used for my personal, non- commercial, non-public use: 3. I understand that work performed on the project must be performed by the following: a. myself as the sole owner of the property; or b. a licensed contractor; or c. my employee(s) on whom I have Workers Compensation Insurance coverage, on whom I withhold and pay all required payroll taxes, and with respect to whom I comply with all other applicable employee/employer laws; or d. any other person working under my supervision as Owner/Builder to whom no compensation or only token compensation is paid; and 4. I understand that if I retain the services of an unlicensed contractor or compensate an unlicensed person, other than token compensation, or other than as an employee for wages, to perform construction services for which licensure is required, I may be guilty of a Class A Misdemeanor and may be additionally subject to an administrative fine in the maximum of $2,000.00 for each day on which I violate the Utah Construction Trades Licensing Act. Dated this day of 20___ Signature of Owner/Builder Subscribed and Sworn before me this day of 20__, in the County of State of Utah. My Commission Expires: Notary Public SUBMIT THIS FORM TO THE BUILDING DEPARTMENT FOR PERMITS. I declare under criminal penalty under the law of Utah that the foregoing is true and correct. Signed on the day of at Date Month Year City or other location, and State or County. Printed name Signature