Date: ______________
| Building Permit #: | ______________________________________________________________ |
| Building Contractor: | ______________________________________________________________ |
| Owner's Name: | ______________________________________________________________ |
| Site Location: | ______________________________________________________________ |
| Plumbing Contractor Electric Contractor HVAC Contractor Specialty Contractor | |
| Licensure Name: | ______________________________________________________________ |
| Company Name: | ______________________________________________________________ |
| State Cert./Reg #: | ______________________________________________________________ |
| Citrus Comp. #: | ______________________________________________________________ |
| Phone #: | ______________________________________________________________ |
I hereby swear that I am in compliance with Florida's Workers Compensation Law and that I have secured coverage or have a valid Certifcate of Exemption.
Signature: _______________________________________________