What is the Workers’ Compensation Addendum for?

It accompanies a building permit application and records the property location, coverage documentation or exemption basis, and the applicant’s verification.

Who completes this addendum?

The applicant for a building permit completes it, selecting whether to attach a certificate of insurance or self-insurance, or an Affidavit of Exemption.

Do I need a notary for the Workers’ Compensation Addendum?

No. The addendum has no notary block; the applicant signs to verify the statements. It lists an Affidavit of Exemption as an attachment option.

Vandergrift, PA · Westmoreland County

No notary required

Workers’ Compensation Addendum

Building permit applicants use this addendum to provide workers’ compensation coverage information or document an exemption for a project in Vandergrift.

What this form is

This addendum accompanies a building permit application and records the property location and parcel details, along with the applicant’s workers’ compensation coverage or basis for exemption. Applicants select whether they are attaching a certificate of insurance or self-insurance, or an Affidavit of Exemption, and provide explanations where requested. The applicant signs to verify the statements and acknowledges requirements concerning subcontractors and project workers.

Who needs it

A building permit applicant for a Vandergrift project needs this addendum to provide coverage documentation or state a basis for exemption.

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 addendum has no notary block; the applicant signs to verify the statements, and an Affidavit of Exemption is listed as an attachment option.

How to submit this form

1
Download The Addendum
Download the Workers’ Compensation Addendum PDF.
2
Complete The Form
Enter the property location, lot and block or parcel number, municipality, and county; select the applicable coverage or exemption option.
3
Gather Attachments
Attach a certificate of insurance or self-insurance, or an Affidavit of Exemption, as applicable.
4
Sign And Submit
Sign to verify the statements, then submit the addendum to the city department named on the form.

Frequently asked questions

What is the Workers’ Compensation Addendum for?: It accompanies a building permit application and records the property location, coverage documentation or exemption basis, and the applicant’s verification.
Who completes this addendum?: The applicant for a building permit completes it, selecting whether to attach a certificate of insurance or self-insurance, or an Affidavit of Exemption.
Do I need a notary for the Workers’ Compensation Addendum?: No. The addendum has no notary block; the applicant signs to verify the statements. It lists an Affidavit of Exemption as an attachment option.
How do I submit the Workers’ Compensation Addendum?: Submit it to the city department named on the form; check the city website for current contact details.

Need something notarized?

This Workers’ Compensation Addendum doesn’t need a notary — but if you have another Vandergrift form that does, a commissioned online notary can help.