Public Act. 96-216 requires that any person engaged in construction, remodeling, refinishing, refurbishing, rehabilitation, alterntion or repair work within the state be convered by Worker's Compensation Insurance, and to produce proof of such coverage to the local Building Official prior to the issuance of a building permit, unless they are specifically exempted under the law. This statement must be completed by any indivdual who does not have such insurance and claims exemption under the law.
I, the undersigned, am the;
( ) Owner in Fee of the referenced property, or
( ) Building Permit applicant, and owner of a contracting business known as:
_______________________________________________________________________
located at: _______________________________________________________________
and I claim exemption from Workers Compensation Insurance requirements as follows:
( ) I am the owner and will be performing all the construction work personally at the above cited property, with the assistance only from members of my immediate family, or;
( ) I am the sole proprietor of the above business, and have no employees as defined under Section 31-275(9)(A) of the Workers Compensation Act as amended.
Furthmore, I understand and agree that I will require proof of Workers Compensation for all those employed on the job site in accordance with the provisions of the Workers Compensation Act.
I understand and agree that failure to comply with the insurance requirements of state law will subject me to civil penalties thereunder. I further understand that falsification, in any way, of the facts or conditions I have represented herein constitutes a false statement for which penalties under the law apply.