Banning, CA · Riverside County
Worker’s Compensation Declaration and Authorized Agent Form
Contractors and construction permit applicants use this form to declare workers’ compensation coverage, construction lending information, and applicant details.
What this form is
This form records a construction permit applicant’s workers’ compensation declaration and, if applicable, construction lending agency information. The applicant also certifies the construction permit application, provides license and contact details, and signs and dates the declaration. An authorized agent applying for a contractor must complete page two and attach a notarized authorization letter stating the agent’s name and authority to apply, pay, and receive permits.
Who needs it
Construction permit applicants complete the declarations, and an authorized agent applying for a contractor must also complete page two and attach the specified authorization letter.
How to submit it
Submit the completed form to the City of Banning Building & Safety Department, 99 E. Ramsey St., P.O. Box 998, Banning, CA 92220.
About notarization
This form is signed without a notary; an authorized agent must attach a notarized authorization letter stating their name and authority to apply, pay, and receive permits.
How to submit this form
- 1
Download The Form
Download the Workers’ Compensation Declaration and Authorized Agent Form.
- 2
Complete The Declarations
Provide the applicable workers’ compensation and construction lending information, then complete the permit applicant details.
- 3
Attach Agent Authorization
If an authorized agent applies for a contractor, complete page two and attach the notarized authorization letter described on the form.
- 4
Submit To The City
Submit the completed form to the City of Banning Building & Safety Department at the address printed on the form.
Frequently asked questions
- What does the Workers’ Compensation Declaration form cover?
- It records the applicant’s workers’ compensation declaration and construction lending agency details, if applicable, along with permit applicant and contractor information.
- Do I need a notary for the Workers’ Compensation Declaration?
- No. The form is signed without a notary. An authorized agent must attach a notarized authorization letter stating their name and authority to apply, pay, and receive permits.
- How do I submit the Workers’ Compensation Declaration?
- Submit the completed form to the City of Banning Building & Safety Department at 99 E. Ramsey St., P.O. Box 998, Banning, CA 92220.
Need something notarized?
This Worker’s Compensation Declaration and Authorized Agent Form doesn’t need a notary — but if you have another Banning form that does, a commissioned online notary can help.