Who completes this form?

A licensed contractor associated with a permit project completes it, providing the project address, license details, and applicable workers’ compensation information.

Do I need a notary for this form?

No. The document is signed without a notary; the workers’ compensation declaration is affirmed under penalty of perjury, and the signer signs and dates the form.

How do I submit this form?

Submit it to the city department named on the form. The document does not provide submission contact details, so check the city website for current information.

West Covina, CA · Los Angeles County

No notary required

Licensed Contractor’s Declaration, Workers Compensation Declaration and Authorization of Entry

Licensed contractors complete this form with license and workers’ compensation details and authorize city inspections for the permit project address.

What this form is

This form combines a licensed contractor’s declaration, workers’ compensation declaration, and authorization for a city representative to enter the project property for inspections. Contractors provide the project address, license details, and applicable workers’ compensation information, then sign and date their declarations. The form is for work associated with a city permit.

Who needs it

A licensed contractor associated with a permit project completes this form to provide license and workers’ compensation declarations and authorize inspections.

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 affirms the workers’ compensation declaration under penalty of perjury and signs and dates the form.

How to submit this form

1
Download the Form
Download the Licensed Contractor’s Declaration PDF.
2
Complete the Declarations
Enter the project address and license details, select the applicable workers’ compensation declaration, and provide insurance information where applicable.
3
Sign and Date
Sign the declarations and authorization of entry, then enter the date.
4
Submit to the City
Submit the form to the city department named on it; check the city website for current contact details.

Frequently asked questions

What is the Licensed Contractor’s Declaration?: It combines a contractor license declaration, workers’ compensation declaration, and authorization for a city representative to enter the project property for inspections.
Who completes this form?: A licensed contractor associated with a permit project completes it, providing the project address, license details, and applicable workers’ compensation information.
Do I need a notary for this form?: No. The document is signed without a notary; the workers’ compensation declaration is affirmed under penalty of perjury, and the signer signs and dates the form.
How do I submit this form?: Submit it to the city department named on the form. The document does not provide submission contact details, so check the city website for current information.

Need something notarized?

This Licensed Contractor’s Declaration, Workers Compensation Declaration and Authorization of Entry doesn’t need a notary — but if you have another West Covina form that does, a commissioned online notary can help.