Workers' Compensation Waiver This Form Requires a Notary Seal AFFIDAVIT OF EXEMPTIONReasons Property owner performing own work. If property owner does hire a 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 these requirements. 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). Use this form when applicable to part "C" on the workers' compensation form. Notary SealSignature of ApplicantCounty ofMunicipality ofSubscribed, sworn to and acknowledged before me by the aboveNameThis DateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SEALNotary PublicMUST BE NOTARIZED
