Essex, CT · Middlesex County
Workers’ Compensation Coverage Exclusion Affidavit
This affidavit documents a general contractor’s or principal employer’s workers’ compensation coverage exclusion when applying for a building permit for a property in Essex.
At a glance
- Issued by
- City of Essex · Essex, Middlesex County, Connecticut
- Notarization
- Required: sign this form in front of a notary before filing it.
- Official source
- ct-essex.civicplus.com
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
- licensed online notary
- ~15 min average
- Notarized PDF emailed
What you’ll need
- Government-issued photo ID
- Webcam-enabled device (laptop or phone)
- This form, ready to upload as a PDF
What this form is
Use this State of Connecticut Form 7C when applying for a building permit if you are a general contractor or principal employer who has properly excluded yourself from workers’ compensation coverage. The form identifies the applicant and property, records the applicable exclusion certificate filed with the Workers’ Compensation Commission, and includes an affidavit promising to require proof of coverage from workers and contractors before they work at the site.
Who needs it
A general contractor or principal employer applying for a building permit who has properly excluded themselves from workers’ compensation coverage may need to complete this form.
Why it needs a notary
The form has a jurat stating “Subscribed and sworn to before me”; the general contractor or principal employer signs the affidavit before a notary public or Superior Court commissioner.
How to get this notarized
- 1
Download Form 7C
Get the State of Connecticut Form 7C used as proof of workers’ compensation coverage for a building permit application.
- 2
Complete the Form
Provide the applicant and property details, check the applicable role and exclusion certificate, and complete the affidavit.
- 3
Book an Online Notary
Schedule a remote notarization for the affidavit’s jurat.
- 4
Sign on Video
Sign the affidavit during the online notary session when instructed.
- 5
Submit With Your Permit Application
Provide the completed form with your building permit application to the appropriate Essex office.
Preview the form
The blank PDF straight from Essex. Look it over, then upload your filled copy to start the notary session.
You’ll need ID and a webcam.
A licensed online notary will join you on video, verify your government-issued ID, witness your signature, and apply their seal. You’ll receive the notarized PDF by email when the session ends.
Frequently asked questions
- How do I complete Form 7C for an Essex building permit?
- Enter the applicant and property information, identify your role and the exclusion certificate filed with the Workers’ Compensation Commission, then sign the affidavit before a notary public or Superior Court commissioner.
- Do I need to sign Form 7C in front of a notary?
- Yes. The form says to sign the affidavit in the presence of a notary public or Superior Court commissioner and includes a “Subscribed and sworn to before me” jurat.
- Can I use online notarization for this affidavit?
- Connecticut authorizes remote online notarization for eligible documents. A commissioned online notary can notarize this affidavit remotely; check with the town clerk if unsure whether the receiving office accepts it.
- Where do I submit the completed form?
- Form 7C is described as proof of workers’ compensation coverage when applying for a building permit. Submit it with your permit application to the appropriate Essex office.