Paxtang, PA · Dauphin County
Worker’s Compensation Affidavit
Building permit applicants use this affidavit to state whether they will hire others for the project and provide information about subcontractors.
What this form is
This affidavit is for a person seeking a building permit who states they will not hire others for the project. It asks whether subcontractors will be used and whether they are covered under the general contractor’s liability insurance; if the signer hires others after receiving the permit, the form says to notify the Borough Office and provide proof of workers’ compensation coverage within three working days.
Who needs it
A person seeking a building permit who will not hire others for the project uses this affidavit and answers its subcontractor questions.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This affidavit has no notary block and is signed without a notary; the signer swears they will not hire others and signs and dates the form.
How to submit this form
- 1
Download The Affidavit
Download the Worker’s Compensation Affidavit PDF.
- 2
Complete The Form
Print your name, answer the subcontractor questions, and sign and date the affidavit.
- 3
Gather Any Related Form
If you answer yes to using subcontractors, the affidavit says to complete the Sub-contractor form.
- 4
Submit The Affidavit
Submit it to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- What does the Worker’s Compensation Affidavit ask?
- It asks the building permit applicant to state that they will not hire others for the project and whether subcontractors will be used and covered under the general contractor’s liability insurance.
- Who uses this affidavit?
- A person seeking a building permit uses it to make the stated hiring declaration and answer questions about subcontractors.
- Do I need a notary for the Worker’s Compensation Affidavit?
- No. The document has no notary block; the signer swears the stated information, then signs and dates the form.
- How do I submit the Worker’s Compensation Affidavit?
- Submit it to the city department named on the form; check the city website for current contact details.