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City of Summersville

400 N. Broad StreetP. O. Box 525

Summersville, WV 26651

(304) 872-1211

 

Directions to Job Site

 

Name of Applicant:______________________________________________________________

 

Directions to Project:  Directions must be submitted before permit will be issued.  Please provide clear and

                                       specific directions to the site below:

 

 

 

 

 

Compliance Verfication

 

·        The general contractor must complete this form and have it notarized prior to issuance of a building permit.

 

To ensure compliance with West Virginia Code 21-11-15 and 28-2-5, satisfactory proof must be furnished that the State Privilege License Fee has been paid and Worker’s Compensation Insurance is in effect.  Please mark the appropriate statements below:

 

·         ___      As a licensed General Contractor of the State of West Virginia, I hereby 

                                       certify that I have obtained Worker’s Compensation as required by West

                                       Virginia Code 23-2-5, and I will maintain the required Worker’s

                                       Compensation Insurance for the entire duration of any construction for

                                       which permits have been issued.

 

·         ___      As a licensed General Contractor of the State of West Virginia, I hereby

                   certify that I am exempt from the requirements of West Virginia Code

                   23-2-5, requiring Worker’s Compensation Insurance for Contractors and

                   their employees.

 

                   And

 

·         ___      I hereby certify that I have paid the West Virginia License Application

renewal fee required for all contractors in pursuant of the West Virginia

Code 21-11-15 and 28-2-5.

 

 

Print Name of License Holder:_____________________________________________________

 

Signature of License Holder:___________________________________Date:________________

 

Contractor’s License Number:______________________________________________________

 

 

 

Sworn to and subscribed before me this _____________day of ___________________,2_______

 

 

                                                            _____________________________________________

                                                            Notary Public

                                                           

My commission expires:__________________________________________________________

City of Summersville Building Permits                                                     Asbestos Agreement 01

 
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