Registration Exemption Affidavit (Fillable) | Fairfield County Building Department

State of Ohio, County of Fairfield Date Date:

I, Representative name , do certify that I am a bonified representative of the following company: Company name , located at Company location/address .

I do hereby request exemption from the contractor registration program due to work being performed by company employees who are employed by the above company and are not and do not represent themselves as contractors as defined by the Ohio Construction Industry Licensing Board.

All work is affiliated with permit # Permit number will be completed at the following location:

Work location address Address City City State State Zip Zip

I UNDERSTAND AND WILL ABIDE BY THE FOLLOWING STIPULATIONS:

The company named above agrees to complete the project(s) and occupy the building during the time of construction.
The company and address named above will be the sole user of the facility.
The company named above will not enter into a contract with a contractor that is not registered with the Fairfield County Building Department.
The company named above will inform the Fairfield County Building Department if it decides to hire a contractor to complete the work.
The company named above will submit all required plans; acquire permits and inspections for the work performed by all company employees. All trade work must be supervised and documented by qualified company personnel.
I understand and agree to all the above stipulations and understand I am responsible for all construction and agree to abide by all building codes of the State of Ohio and resolutions of Fairfield County Building Department:

Name of Applicant - Please type or print

Signature of applicant

Business Phone Number

Alternative Phone Number

Sworn to before me and signed in my presence this Sworn day day of Sworn month , in the year 20 Year (last two digits) .

Notary Seal Here

Notary Public

FALSIFICATION OF A PUBLIC DOCUMENT IS A VIOLATION OF THE OHIO REVISED CODE, SECTION 2921.13 (A) (3), A MISDEMEANOR OF THE FIRST DEGREE, PUNISHABLE BY UP TO SIX (6) MONTHS IMPRISONMENT AND A FINE OF $1,000 OR BOTH.

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