Form 110 "Permit Declarations" - City of Berkeley, California 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the project address and permit number at the top of the form. This information is crucial for identifying your application.
3. For licensed contractors, complete the Licensed Contractor’s Declaration and Information section. Fill in your company name, license number, class, and expiration date.
4. Property owners must complete the Owner Builder Declaration. Indicate your exemption status by checking the appropriate boxes and provide a signature.
5. If applicable, fill out the Worker’s Compensation Declaration. Choose one of the options regarding workers’ compensation coverage and provide necessary details such as carrier name and policy number.
6. Review all declarations carefully to ensure accuracy before signing at the bottom of the form. Your signature affirms that all information provided is true under penalty of perjury.

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