Fillable Denver SUPERVISOR’S STATEMENT OF RESPONSIBILITY

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Denver SUPERVISOR’S STATEMENT OF RESPONSIBILITY

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______________________________________________________________________________
______________________________________________________________________________
SUPERVISOR’S STATEMENT OF RESPONSIBILITY
This form must be submitted for all licenses that require a supervisor certificate holder.
The only license types that do not need to submit this document are electrical, plumbing,
and right-of-way (ROW).
I, ______________________________, am employed by________________________________
(name) (company name)
________________________________ in an ACTIVE, FULL-TIME capacity as SUPERVISOR
(company name continued)
for all work performed under the company’s ___________________________________ license.
(license type)
My residential or local address (if from out of state) is:
My daytime telephone number is _____________________________.
My Supervisor certificate number is __________________________.
My Supervisor certificate type is _____________________________.
I have read Chapter 1 of the Denver Building and Fire Code and hereby acknowledge that
I must adhere to the requirements of the code: www.denvergov.org/buildingcode.
SIGNED: ________________________________________________
DATED: _________________________________________________
Community Planning and Development
201 W. Colfax Ave., Dept. 205 | Denver, CO 80202
www.denvergov.org/contractorlicensing
p. 720.865.2770
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Denver SUPERVISORS STATEMENT OF RESPONSIBILITY

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Completed 15 January 2020

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