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 Applicant County of Municipality of Subscribed, sworn to and acknowledged before me by the aboveName This DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SEAL Notary Public MUST BE NOTARIZED
