Building Permit Application Submittal | Manufactured And Industrialized Housing BUILDING PERMIT APPLICATION SUBMITTAL | MANUFACTURED AND INDUSTRIALIZED HOUSING 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 Property owner performing own work. If property owner does hire contractor to perform any work pursuant to building permit, contractor must provide proof of workers' compensation insurance to the municipality. Homeowner assumes liability for contractor compliance with this requirement. Contractor has no employees. Contractor prohibited by law from employing any individual to perform work pursuant to this building permit unless contractor provides proof of insurance to the municipality. Religious exemption under the Workers' Compensation Law. All employees of contractor are exempt from workers' compensation insurance (attach copies of religious exemption letter for all employees). Signature of ApplicantCounty of Municipality of Subscribed, sworn to and acknowledged before me by the above _______________________ this _______ Day of ____________ 20______.Seal Notary Public _______________________