E-Permits
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*Applicant Name
*Password 5 to 10 letters or digits only
*Confirm Password
*Address
*City
*State
*Zip Code
*Phone Example: 650-123-4567
*Email
*Applicant Type

If you are a contractor, the next 5 fields below are required
Company Name
Contractor License #
Contractor License Class
Workers' Comp. Carrier
Workers' Comp. Policy #

Optional Credit Card Billing Information
Cardholder's Name
Address
City
State
Zip Code

 

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