| CONTRACTOR
REGISTRATION FORM UPPER PROVIDENCE TOWNSHIP |
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| 935 N. Providence Rd., Media, PA 19063 • (610) 565-4944 • FAX (610)565-8924 | |
| I. The applicant for the
building permit, in compliance 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 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 corporation, and the only employees working on the project have and are qualified as "Executive Employees" under Section 104 of the Workers' Compensation Act. Please explain: _____________________________________________________________________ _____________________________________________________________________ ___ All of the contractor/applicant's employees on the project are except on religious grounds under Section 304.2 of the Workers' Compensation Act. Please explain: _____________________________________________________________________ _____________________________________________________________________ ___ Other. Please explain: _____________________________________________________________________ _____________________________________________________________________ Name of Applicant ______________________________________________________ Address ______________________________________________________________ City ____________________________________ State_____ Zip Code ____________ Applicant's federal or state employer identification number (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 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. ************************************OFFICE USE ONLY********************************** $75.00 fee received on ____________, Check No. ___________________, Received by________________ My signature on behalf of or as the contractor/applicant for this building permit constitutes my verification that the statements contained here are true, and that I am subject to the penalty of 18 P C.S.A. 4904 relating to unsworn falsifications to authorities. _____________________________________ Signature _____________________________________ Name (Please Print) _____________________________________ Title _____________________________________ Name of Company In witness whereof, I hereunto set my hand and official seals ____________________________________ Notary Public __________________________________________ Pennsylvania League of Cities and Municipalities Note: Applicant's Copy to be attached to permit and posted. Municipality's copy to be filed with its permit copy. MUST BE SIGNED IN PRESENCE OF NOTARY |
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| CLOSE WINDOW | |