Building Permit Application Submittal | Detached Structures

BUILDING PERMIT APPLICATION SUBMITTAL | DETACHED STRUCTURES

The undersigned affirm that he/she is not required to provide workers compensation insurance under the provisions of Pennsylvania's Workers' Compensation Law for one of the following reasons, as indicated:
Workers' compensation insurance
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Subscribed, sworn to and acknowledged before me by the above _______________________ this _______ Day of ____________ 20______.
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Notary Public _______________________