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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.




·         ___      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