Form 7B (PDF)

7A - 7B - 7C
DIRECTIONS
Building Permit Requirements for Workers’ Compensation
DIRECTIONS for FILING FORMS 7A, 7B and 7C
Rev. 3-17-2006
State of Connecticut
Workers’ Compensation Commission
What to give to the Building Official to obtain a Building Permit:
1.
The General Contractor or Principal Employer must provide a written certificate of workers’
compensation insurance for all of the employees on their project. This certificate may not be for liability,
disability or any other type of insurance.
2.
The Sole Proprietor or Property Owner who will not act as a general contractor or principal
employer is not required to have workers’ compensation coverage. In order to obtain the building
permit, a FORM 7A should be completed and given to the building official.
3.
The Sole Proprietor or Property Owner who will act as a general contractor or a principal
employer must provide a written certificate of workers’ compensation insurance for all of the
employees on their project and must file a FORM 7B with the building official — OR he will sign a sworn
notarized affidavit on FORM 7B, stating that he will require proof of workers’ compensation insurance
for all those employed on the job site.
4.
The General Contractor or Principal Employer who has properly excluded himself from
coverage using the appropriate WCC form (see NOTE below) must file the FORM 7C with the building
official. This form certifies that they have properly excluded themselves, and attests that they will
require proof of workers’ compensation insurance from every employee that works on the designated
job site.
NOTE:
The general contractor or principal employer may exclude himself from workers’ compensation
coverage by filing one of the following forms with the appropriate Workers’ Compensation
Commission district office:
Form 6B for employees who are Officers of a Corporation or Managers / Members of an LLC
Form 6B-1 for employees who are Members of a Partnership
Section 31-286b of the Workers’ Compensation Act requires anyone who requests a building permit to first
submit “proof of workers’ compensation coverage for all of the employees who are engaged to perform
services on the site of the construction project for which the permit was issued.”
The only exceptions to this law are the sole proprietor or property owner who will not be acting as general
contractor or principal employer.

7B
Proof of Workers’ Compensation Coverage when Applying
for a Building Permit for the Sole Proprietor or Property Owner
who WILL act as General Contractor or Principal Employer
Please TYPE or PRINT IN INK
Rev. 3-17-2006
State of Connecticut
Workers’ Compensation Commission
ATTEST
If you are the owner of the above-named property or the sole proprietor of a business doing work on the site of the construction project at the above-named
property and you WILL act as the general contractor or principal employer, you must provide proof of workers’ compensation insurance coverage for all
employees.
Complete this form and, if applicable, sign the Affidavit below in the presence of a Notary Public or a Commissioner of the Superior Court.
CHECK ONE (1) BOX ONLY, provide the appropriate information, and sign:
‰ I am the OWNER of the above-named property. I WILL act as the general contractor or principal employer and, as such, will submit proof of workers’
compensation insurance coverage for all employees who are doing work on the site of the construction project at the above-named property.
Signature of OWNER Applicant
‰ I am the SOLE PROPRIETOR of a business doing work at the above-named property. I WILL act as the general contractor or principal employer and, as
such, will submit proof of workers’ compensation insurance coverage for all employees who are doing work on the site of the construction project at the above-
named property.
Signature of SOLE PROPRIETOR Applicant
‰ I am the OWNER of the above-named property or the SOLE PROPRIETOR of a business doing work at the above-named property. I will not personally
submit proof of workers’ compensation insurance coverage, but I will attest to the following:
AFFIDAVIT
I hereby swear and attest that I will require proof of workers’ compensation insurance for every contractor,
subcontractor, or other worker before he or she does work on the site of the construction project at the
above-named property in accordance with Section 31-286b of the Workers’ Compensation Act.
Signature of OWNER or SOLE PROPRIETOR Applicant
Name of Business—if applicable
Federal Employer ID# (FEIN)—if applicable
Subscribed and sworn to before me this
day of
,  200
.
Signature of Notary Public / Commissioner of the Superior Court
APPLICANT FOR BUILDING PERMIT
Name of Applicant for Building Permit
Property located at
in the City / Town of
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WATERFORD