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 covering them,

_______ has/have one or more subcontractor(s) who has/have their own policy of workmen’s 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 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