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The undersigned affirms that he/she is not required to provide workers compensation insurance under the provisions of Pennsylvania’s Worker’s Comprehension Law for one of the following reasons, as indicated.

Property owner performing own work. If property owner does hire 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 this requirement.

Initials

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.

Initials

Religious exemption under the Workers’ Compensation Law. All employees of contractor are exempt from workers compensation insurance (attach copies of religious exemption letters for all employees).

Initials

I/We, the undersigned owner(s) of a proposed single family residential dwelling/commercial located at

Address

I/We acknowledge that in requesting that the Township waive this requirement with respect to the residential structure to be erected on the aforementioned property, that we waive any and all claims against Peters Township, its officers, agents, employees, contractors or representative for any and all claims, including but not limited to deficiencies, faults, structural flaws, or claims arising out of the design and construction of the premises.

I/We acknowledge that no architect/engineer seals or approvals have been made with respect to the structure and execute this acknowledgement and waiver on behalf of my/our heirs, successors, representatives and assigns.

I/We further acknowledge that in the Township’s sole prerogative, this document may be made a matter of Township record and disclosed to successor owners of the property in question. I/We further acknowledge that this document may be recorded in the Office of the Recorded of Deeds of Washington County, Pennsylvania, and I/We will be responsible for any recording costs incidental thereto.

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