The undersigned applicant for Building Permit # _________________ being the
________________________________________ Contractor
________________________________________ Owner
________________________________________ Officer/Agent of the Contractor or Owner
Do hereby aver under penalties of perjury that the person(s), firm(s) or corporation(s) performing the work set forth in the permit:
______ has/have three (3) or more employees and have obtained workers’ compensation insurance to cover them,
______ has/have one or more subcontractor(s) and have obtained workers’ compensation insurance to cover them,
______ has/have one or more subcontractor(s) who has/have their own policy of workers’ compensation covering themselves,
______ has/have not more than two (2) employees and no subcontractors,

while working on the project for which this permit is sought. It is understood that the Inspection Department issuing the permit may require certificates of coverage of workers, compensation insurance prior to issuance of the permit and at any time during the permitted work from any person, firm or corporation carrying out the work.

Firm name: ________________________________________
By: ______________________________________________
Title: _____________________________________________
Date: _____________________________________________
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