Category: Permitting

Certification for Wetlands/Buried Solid Waste




I hereby certify that I am fully aware of, and acknowledge that construction on or use of any property may be significantly restricted or totally prohibited by Federal Law. Lands that are identified as “wetlands” by the United States Army Corps of Engineers cannot be used unless and until a permit is issued by the Corps. Before commencing subdivision, construction or any other improvement of any land, the owner or his/her agent should contact either the Corps of Engineers or a qualified professional to determine whether or not said land could be considered either in whole or in part a “wetland.” The Corps has the authority to require the removal of any improvement placed within a “wetland” by the owner of such land regardless of the cost of the removal or other effect upon the landowner.

No agent or employee of the municipality in which this work will be performed has made any effort to determine whether or not all or a portion of said land constitutes a “wetland.” The granting of a building permit, occupancy permit, onsite sewage disposal permit, or subdivision approval by the municipality DOES NOT in any way imply that the land does NOT constitute a “wetland,” or that a permit has been issued by the Corps to place an improvement upon the land, or that it is not necessary to determine if any portion of the land constitutes a “wetland.” Any person who proceeds with subdivision, construction, or the placing of any improvement upon land without prior Corps review and/or approval does so AT HIS OWN RISK WITHOUT ANY RESPONSIBILITY ON THE PART OF THIS MUNICIPALITY, ITS AGENTS OR EMPLOYEES!



I hereby certify that I have not buried any solid waste on the property of this application. I acknowledge that the Commonwealth of Pennsylvania Solid Waste Management Act specifically prohibits the disposal of solid waste except at legally permitted landfills.

I understand that violation of this act may result in prosecution by appropriate agencies of the Commonwealth.


Applicant signature: ____________________________________ Date: _______________


Name of applicant (please print): _____________________________________________


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Pennsylvania Workers’ Compensation Insurance Coverage Information Form


Please complete all applicable sections of this form paying special attention to the documentation requirements listed in each section. The building and/or zoning permit that you are requesting will not be issued until this form is completed properly.

1. Are you the homeowner/property owner performing the work (as requested in this application) yourself?

☐ No – go to question #2

☐ Yes – read this exemption statement, sign to indicate your understanding and submit this form with your application “Homeowner swears/affirms that he/she will be performing all work on this project and no outside contractors will be employed on this project.”

Signature: ___________________________________ Date: _____________

2. Are you the homeowner/property owner who has hired a contractor to perform the work (as requested in this application)?

☐ No – go to question #3

☐ Yes – please have your contractor complete Sections A & B

3. Are you the contractor hired by the homeowner/property owner to perform the work as requested in this application)?

☐ Yes – complete Section A & B

☐ No – please explain: _______________________________________________________________

A. Name of Company ___________________________________________

Contact person ___________________________________ Phone # _________________________

Address of company ________________________________________________________________

Federal or State Employee Identification # ________________________

Please select one of the following options:

☐ Applicant is a qualified self-insurer for workers’ compensation

Please attach a copy of the insurance certificate listing the municipality in which the work will be performed as a certificate holder

☐ Applicant carries workers’ compensation coverage with an insurance company

Please attach a copy of the insurance certificate listing the municipality in which the work will be performed as a certificate holder

☐ Applicant is exempt from providing workers’ compensation insurance because:

☐ The contractor is a sole proprietorship without employees (The contractor is prohibited by law from employing any individual to perform work pursuant to this building permit unless contractor provides proof of insurance to the municipality.)

☐ All of the contractor’s employees on the project claim an exemption based on religious grounds as defined in Section 304.2 of the Workers’ Compensation Act.

Note: If you are requesting an exemption from the Workers’ Compensation Act requirements, you must sign in Section B in front of a notary public.

Will you be using any subcontractor(s) on this project? ☐ NoYes  (if yes, all subcontractors must present proof of insurance as required under the Pennsylvania Workers’ Compensation Act.)

B. My signature as the contractor indicates my understanding of the requirements to provide proof of Workers’ Compensation insurance as needed and verifies that all statements made above are true. I understand that if I am a contractor requesting an exemption under the Workers’ Compensation Act that I must sign this form in front of a notary public.

Signature _____________________________________ Date ____________

Address ___________________________________________________________________________


County _________             Municipality of _______________________

My commission expires:                                                   Subscribed and sworn to before me this-

________ day of _____________ 20___.

SEAL                                                                                          _________________________________

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