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ation of Exemption Ne Workers’ Certificate of Attest ensation and/or from New York State Workers’ Comp srate | Compensation Fam ily Leave Benefits In surance Coverage Board Dis abi lit y and Pai d party.** or obligations of any ve the wor ker s 'eompensation rights «This form cannot be us ad to wai that New York State ion ON LY to sho w a government entity of Exempt required. ‘I he applicant Certifi cate of Attestation ve benefits instance is not The applicant may use this paid fami ly lea ion and/or disabili ty and insurance is not required. specific workers’ compensat ness 's inst irance carrier that such will to show another business or that busi contract. This Certificate may NOT use this form fre m whi ch you are req uesting @ perry if; Hicense or io the povernment entity form. Please provide this form after the date printed on the ern ment 0 fficials one year lying For: nat be accept ed by gov Business App Building Permit in the Application of ress): (Legal Entity Name and Add From: Tewn af Wales Mosie Shetlec is sshz N HERE The location of where wor k will be performed WY 14740-9820 ra, my 14052. [3781 Schany Road, East Auro Gerry TEEN: ARN A NOTOS PHONE: 936-368-918 ed with the balding complete work associat Estimated dates necessary to 1, 2026 to De cember 1, 2026. | permitare from Novem ber t is $50,001 = $100,000 The estimated dollar amount of projec Workers: Compensation Ex RK STATE SPECIFIC is certi fying that it is NOT REQ UIR ED T O OBTAIN NEW YO The above named business NCE COVE RAGE for the follnoowin g reason: _— WORKERS® COMPENSATION INSURA than the owner , there arc employees, day labor, leasea idual and is not a corporation. Other ntractors. The busmess 7s owned by one spdjv ( including family members) oF subco part- time employees, unpaid volunteers employees, borrowed employees, its Exem i Disability and Paid Family Leay e Benef NEW YORK STA TE STATUTORY it is NOT REQUIRED T © OBTAIN The above named business i s certifying that for the following reason: FA MILY LEAV E BENE FITS INSURANCE CO VERAGE DISABILITY AND PAID PLLP, RLLE, or LP) ander be either : 1) owne d by one indiv idual , OR 2 } is a partnership (ineluding L LC, LLP, those individuals ownmg The business MUST d corporation, with ration; OR 3) is a one or two person owne own ihe laws of New York State and is nota corpo n (in a two perso n pwne d corpo ratio n each individual must be an officer and ng all office s of the corpo ratio re disab ility and paid all ef the stock and holdi business does not requi ess with no NYS location. In addition, the a8 least one share of stock); OR 4) isa busin has not employed one or more individual s on at least 30 days in any calendar year in family leave benefits coverage at this time sincenotit consi dered to be employees under the Disability and Paid Family Leave Benefits Law) New York State. Undependent contractors are Propricior with the above-named Jegal c tity, | affirm that due to my position with 1, Mosie Shetler, am the Sole prie d io make this Centifici ion by affi -teewiedge, information and penis and |