CITY OF THOUSAND OAKS
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
2100 Thousand Oaks Blvd., Thousand Oaks, California 91362
Phone: (805) 449-2500
FAX: (805) 449-2575

FAX SERVICE PERMIT APPLICATION AND AUTHORIZATION

CONTRACTOR INFORMATION

Company Name:______________________________________________________________

License No.:_______________________________ License Class:______________________

Expiration Date:____________________________

Street Address:______________________________________________________________

City, State, ZIP:______________________________________________________________

Telephone No.: ____________________________   FAX No.: _________________________

E-mail:____________________________________________________

WORKERS’ COMPENSATION INFORMATION

Insurance Company:__________________________________________________________

Policy No.:_____________________________________ Expiration Date:________________

The undersigned give the City of Thousand Oaks Community Development Department permission to accept a facsimile of my signature on a faxed permit application in lieu of my in-person signature at your office. I hereby certify that I will comply with any and all declarations and agreements on the faxed permit application that bears my signature.

The following employee(s) have my permission to obtain permits in the name of my company:

Print Name(s):  

 _________________________________________________________________

                       _________________________________________________________________

Signature(s):   

_________________________________________________________________

                        _________________________________________________________________

Contractor’s Name (print):___________________________________________

Contractor’s Signature:______________________________________________

Date:__________________________