Fillable Affidavit of Assurances Pursuant of KRS 198B.060 (City of JEffersontown)

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Affidavit of Assurances Pursuant of KRS 198B.060 (City of JEffersontown)

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City of Jeffersontown – Affidavit of Assurances 20190115 Page 1 of 1
City of Jeffersontown
Department of Permitting and Enforcement
10416 Watterson Trail
Jeffersontown, KY 40299
Phone: (502) 267-8333 Fax: (502) 267-0547
jeffersontownky.gov
Affidavit of Assurances
Pursuant of KRS 198B.060
(Please Print)
Permit Location / Address: ___________________________________________________________________
Description of Project: ______________________________________________________________________
Comes the Applicant, (Please Print Name)_______________________ and states pursuant to KRS
1988.060(10), that all contractors and subcontractors employed or that will be employed on any activity
under the above referenced project shall be in compliance with the Commonwealth of Kentucky
requirements for Workers' Compensation Insurance (according to KRS Chapter 342) and Unemployment
Insurance (according to KRS Chapter 341).
This the ________ day of ____________________, 20 _____. .
__________________________________________
CONTRACTOR, OWNER OR OWNER'S AGENT
The foregoing Affidavit of Assurances was acknowledged and sworn to before me by
__________________________, Applicant, on this the ________ day of ____________________, 20 _____.
_________________________________________
NOTARY PUBLIC
KENTUCKY STATE AT LARGE
MY COMMISSION EXPIRES ________________________, 20_____.
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Affidavit of Assurances Pursuant of KRS 198B.060 (City of JEffersontown)

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Completed 30 June 2021

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