CA PERMITS & DESIGN

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New Contractor Form

Contractor Details:

Company Name

First name

Last name

Phone

Full Business Address

CSLB License:

License Number

Expiration Date

Workers' Compensation:

I hereby affirm under penalty of perjury one of the following declarations:

I have and will maintain a certificate of consent to self-insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Section 3700of the Labor Code, for the performance of the work for which this permit is issued.

I have and will maintain workers' compensation insurance, as required by Section 3700of the Labor Code, for the performance of the work for which this permit is issued.

I certify that, in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Section 3700of the Labor Code, I shall forthwith comply with those provisions.

Carrier

Policy Number

Agent

Agent or Carrier Phone

By submitting this form, I confirm that I’ve read and agree to the Terms & Conditions.

I affirm, under penalty of perjury, that all information I’ve provided on this form is true and correct.