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Addendum to Building Permit

Submit Certificate of Workers' Compensation Insurance with Sewickley Borough as certificate holder or complete the Addendum to Building Permit Form below.

I. The applicant for the building permit, incompliance with Act 44 of 1993, hereby submits (check one):

Certificate of Insurance (please attach)
Certificate of Self-Insurance (please attach)
Affidavit of Exemption

II. If a certificate of Insurance of Self-Insurance has been submitted, please complete the following:

Name of Insurer or Self-Insurer

Address

Name of Contractor/Policyholder

Address

Contractor/Policyholder’s Federal or State Employer Identification # (EIN)

1. This policy provides coverage for the requirements of the Workers’ Compensation Act, the Occupational Disease Act, and, where applicable, the Federal Longshore and Harbor Workers’ Compensation Act. 2. The insurer has been notified that the municipality issuing the building permit is to be named a policy certificate holder. 3. Any subcontractors used on this project will be required to carry their own workers’ compensation coverage. 4. The contractor/policyholder will notify the municipality of any change in status, cancellation, or expiration of workers’ compensation coverage. 5. Violation of the Workers’ Compensation Act or the terms of this permit will subject the contractor/policyholder to a stop-work order and other fines and penalties as provided by law.

III. If an exemption is being claimed, please complete the following and sign in the presence of a notary public: Basis for exemption (check one):

Applicant is an individual who owns the property
Contractor/Applicant is a sole proprietorship without employees
Contractor/Applicant is a corporation, and the only employees working on the project have and are qualified as “Executive Employees” under Section 104 of the Workers’ Compensation Act
All of the contractor/applicant’s employees on the project are exempt on religious grounds under Section 304.2 of the Workers’ Compensation Act.
Other.

Please Explain

If you have chosen one of the last three boxes, please explain.

Name of Applicant

Address

Applicant’s Federal or State Employer Identification # (EIN)

1. Any subcontractors used on this project will be required to carry their own workers’ compensation coverage.

2. The applicant is not permitted to employ any individual to perform work on this project pursuant to the permit in violation of the Act.

3. Violation of the Workers’ Compensation Act or the terms of this permit will subject the applicant to a stop-work order and other fines and penalties provided by law.

*Original signature mandatory. Please print, sign, and submit to the Building Inspector.*

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