"The head of a state or municipal department, board, commission
or office authorized or required by law to issue any permit for or
in connection with any work involving the employment of employees
in a hazardous employment defined by this chapter, and notwithstanding
any general or special statute requiring or authorizing the issue
of such permits, shall not issue such permit unless proof duly subscribed
by an insurance carrier is produced in a form satisfactory to the
chair, that compensation for all employees has been secured as provided
by this chapter. Nothing herein, however, shall be construed as creating
any liability on the part of such state or municipal department, board,
commission or office to pay any compensation to any such employee
if so employed."
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I, the undersigned, hereby assert under oath that I personally
will do all the work or labor required on or in any way connected
with the following job:
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Give General Description of Job
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Applicant
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Address ______________________________ Phone
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Owner
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Address ______________________________ Phone
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It is imperative that the party authorizing the work to be done
on the above job sign this affidavit.
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Notary Public
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Sworn to before me this _____ day of
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Year __________
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Signature
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Address
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