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
Subscribed, sworn to and acknowledged before me by the above _______________________ this _______ Day of ____________ 20______.
Seal

Notary Public _______________________