13A-64 (rev. 08/18)Construction Project Experience 1. QUALIFIER222S (OWNER - BUILDER) FULL LEGAL NAME L ast F irst M iddle PHONE NUMBER () 2. PROJECT STREET ADDRESS Number/Street Only 226NOP.O. BoxesCityStateZIP Code 3. START DATE Month/Day/YearCOMPLETION DATE Month/Day/YearTOTAL 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. BUILDING PERMIT NUMBER (Please attach a copy of your building permit and final inspection record to this project document .) Permit # 8.YOUR DUTIES AND WORK YOU PERFORMED (For example: prepared plans, obtained permits, installed all sheetrock, installed 4-ton HVAC unit) 9.YOUR POSITION LEVEL (For example: trainee, apprentice, journeyman, supervisor) 10. EXPLAIN HOW PAST EXPERIENCE, TRAINING, AND/OR EDUCATION PREPARED YOU FOR THE POSITION AT THE LEVEL STATED IN #8 ABOVE 11. SCOPE OF WORK (For example: placed 600 sf of mix & sod, installed 2500 sf of concrete tile roof, poured 12 yds of concre te drive, installed 20 linear ft. of cabinetry) 12. NUMBER OF LABORERS AND THE TRADES THEY PERFORMED 13. NUMBER OF GENERAL CONTRACTORS OR SUBCONTRACTORS AND THE TRADES THEY PERFORMED 14. COST OF MATERIALS OR TOTAL COST OF PROJECT *project-LIST* FOR CSLB USE ONLY CONTRACTORS STATE LICENSE BOARD 9821 Business Park Drive, Sacramento, CA 95827 Mailing Address: P.O. Box 26000, Sacramento, CA 95826 STATE OF CALIFORNIA 800-321-CSLB (2752) www.cslbca.govConstruction Project Experience This form must be completed ONLY if the qualifying individual indicates on theCertification ofWork Experience form thathe or she obtained experienceworking self employed, or asotherwise requestedby CSLB. Use a separate form for each project. If you need additional forms, please make a copy of this blank form or visit CSLB222s website.Please type or print neatly and legibly in black or dark blue ink. Incomplete forms are not accepted. American LegalNet, Inc. www.FormsWorkFlow.com