Livermore, CA · Alameda County
Workers' Compensation and Contractor Declaration
This declaration page is completed by permit applicants to certify workers' compensation coverage and provide contractor license or owner-builder information.
What this form is
This form records workers' compensation coverage or an exemption, contractor license details or an owner-builder declaration, and construction lender information if applicable. It accompanies a permit application to the City of Livermore and asks the applicant to certify the information, agree to applicable conditions, and sign and date the form.
Who needs it
A permit applicant completing the related application should provide the applicable workers' compensation and contractor or owner-builder declarations.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This document is signed without a notary; the signer makes declarations under penalty of perjury and signs and dates the form.
How to submit this form
- 1
Download The Declaration Page
Download the Livermore Declaration Page PDF.
- 2
Complete Applicable Sections
Enter the requested workers' compensation, contractor or owner-builder, and lender information as applicable.
- 3
Review And Sign
Certify that the information is correct, then sign and date the form.
- 4
Submit With The Permit Application
Submit the declaration page with the permit application to the city department named on the form.
Frequently asked questions
- What does the Livermore Declaration Page ask for?
- It asks for workers' compensation coverage or exemption details, contractor license information or an owner-builder declaration, and construction lender information if applicable.
- Who completes this declaration page?
- The applicant for the related permit completes the applicable sections, provides the requested details, and signs and dates the form.
- Do I need a notary for the Livermore Declaration Page?
- No. The form has no notary block; the signer makes declarations under penalty of perjury and signs and dates it.
- How do I submit the Livermore Declaration Page?
- Submit it to the city department named on the form; check the city website for current contact details.
Need something notarized?
This Workers' Compensation and Contractor Declaration doesn’t need a notary — but if you have another Livermore form that does, a commissioned online notary can help.