Free FORM - Connecticut

Please TYPE or PRINT IN INK

Proof of Workers' Compensation Coverage when Applying for a Building Permit for the Sole Proprietor or Property Owner who WILL NOT act as General Contractor or Principal Employer
APPLICANT FOR BUILDING PERMIT
Name of Applicant for Building Permit

Property located at

in the City / Town of

ATTEST
If you are the owner of the above-named property or the sole proprietor of a business doing work on the site of the construction project at the above-named property and you WILL NOT act as the general contractor or principal employer, you are not required to have workers' compensation insurance coverage.

CHECK ONE (1) BOX ONLY and complete the following:

I am the OWNER of the above-named property. I WILL NOT act as the general contractor or principal employer.

Signature of OWNER Applicant

I am the SOLE PROPRIETOR of a business doing work at the above-named property. I WILL NOT act as the general contractor or principal employer.

Name of Business

Federal Employer ID# (FEIN)

Signature of SOLE PROPRIETOR Applicant













































































Rev. 3-17-2006

State of Connecticut Workers' Compensation Commission

7A