Heads up: There are no suggested sections in this chapter.
Heads up: There are no amended sections in this chapter.
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 worker's 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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