Perkasie, PA · Bucks County
Workers’ Compensation Insurance Addendum to Building Permit
Building permit applicants submit this addendum to provide workers’ compensation insurance information or claim an exemption for the project.
What this form is
Perkasie’s Code Enforcement Department uses this addendum with a building permit to document workers’ compensation coverage or an exemption. Applicants select and attach an insurance or self-insurance certificate, or provide exemption details; the form also requests applicant, contractor, insurer, policy, and project information. The signed statements address coverage responsibilities and verification.
Who needs it
Applicants for a building permit complete this addendum to provide proof of workers’ compensation coverage or state the basis for an exemption.
How to submit it
Attach the completed addendum to the building permit. The form says the applicant’s copy is attached to the permit and the municipality’s copy is filed with the permit copy.
About notarization
This document is signed without a notary; the applicant signs and dates the verification, which refers to unsworn falsification.
How to submit this form
- 1
Download The Addendum
Download the Workers’ Compensation Insurance Addendum to Building Permit.
- 2
Complete The Form
Provide the requested applicant, contractor, project, and insurance details, or complete the exemption section.
- 3
Gather Attachments
If submitting workers’ compensation or self-insurance coverage, attach the certificate.
- 4
Sign And Attach
Sign the verification and attach the completed addendum to the building permit.
Frequently asked questions
- What is the Workers’ Compensation Insurance Addendum?
- It is an addendum to a building permit where applicants provide workers’ compensation insurance information or explain the basis for an exemption.
- Do I need a notary for the Workers’ Compensation Insurance Addendum?
- No. The applicant signs the verification without a notary; it refers to unsworn falsification.
- How do I submit the Workers’ Compensation Insurance Addendum?
- Attach the completed addendum to the building permit. The form says the applicant’s copy is attached to the permit and the municipality’s copy is filed with the permit copy.
- What should I include with the addendum?
- If submitting workers’ compensation or self-insurance coverage, attach the certificate. If claiming an exemption, complete the exemption section and explain the basis where requested.
Need something notarized?
This Workers’ Compensation Insurance Addendum to Building Permit doesn’t need a notary — but if you have another Perkasie form that does, a commissioned online notary can help.