CITY OF THOUSAND OAKS
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
2100 Thousand Oaks Blvd., Thousand Oaks, California 91362
Phone: (805) 449-2500 FAX: (805) 449-2545

PERMIT BY FAX APPLICATION

LEGAL DECLARATIONS:

LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of division 3 of the Business and Professions Code, and my license is in full force and effect.

License No.________________________________ Class__________________________

Contractor (print)____________________________________ Date__________________

Contractor Phone Number (______)_________________________

WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, or a Certified copy thereof (Sec. 3800 Lab. C)

Company_____________________________________ Policy No. ___________________

____ Certified copy is hereby furnished.

Applicant ___________________________________________ Date _________________

CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for $100 or less)

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.

Applicant ___________________________________________ Date _________________

Notice to applicant: If after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked.

_______________________________________________________
Signature of Contractor or Authorized Agent

WARNING:  Failure to secure workers' compensation coverage is unlawful, and shall subject an employer to criminal penalties and civil fines up to one hundred thousand dollars ($100,000), in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest, and attorney's fees.

PAYMENT INFORMATION

Credit Card Type: (circle one)    VISA    MasterCard

Name of Cardholder: _________________________________________

Card Number : ____________________________ Expiration Date: _______________

Credit card billing address:

Street Number: _______________ Zip Code: _______________

    For Office Use Only:

    Authorization Number: __________________

    Permit Number: ______________    Amount: $ __________ 

 

SITE INFORMATION

Project Address: City: ZIP:
Property Owner: Phone:
Mailing Address: City/State: ZIP:

 

PERMIT INFORMATION

PLUMBING PERMIT

Water Closets: Sinks: Bath/Showers:
Washer: Dish Washer: Total Fixtures:
Gas Pipe/Outlets: Water Heater: Water Piping:
Sewer Line: Resi. Sprinklers:
Other/Explain:

MECHANICAL PERMIT

FAU (btu's): A/C Unit (ton's):
Wall Heater (size): Solar System:
Ducts (number): Exhaust Fans:
Other (describe):

ELECTRICAL PERMIT

Service Upgrade (size): SubPanel (size):
Lights: SW: Outlets: Total (Number):
Motors (HP & type):
Other (describe):