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Sub-Contractor Declaration Form

BLDG PERMIT #(s):____________________________________


PROJECT ADDRESS:___________________________________

General Contractor Information for Project


Company Name:______________________________________________________

State Contractors License Number:________________________________________

Print Name:__________________________________________________________

Signature:_________________________________ Date:______________________

This is to certify that the following company is the PLUMBING subcontractor and is responsible for
work as specified on the above referenced permits.

Company Name: ________________________________________________________________________

State Contractors License Number: ________________________________________________________

Multi-Jur Business License Number: ________________________________________________________

This is to certify that the following company is the ELECTRICAL subcontractor and is responsible for
work as specified on the above referenced permits.

Company Name: ________________________________________________________________________

State Contractors License Number: ________________________________________________________

Multi-Jur Business License Number: ________________________________________________________

This is to certify that the following company is the MECHANICAL subcontractor and is responsible for
work as specified on the above referenced permits.

Company Name: ________________________________________________________________________

State Contractors License Number: ________________________________________________________

Multi-Jur Business License Number: ________________________________________________________

(Please Type Form or Print Legibly)

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