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101.648(4) (4) The department shall prescribe and furnish a waiver application form to each political subdivision that issues building permits for dwellings. The form shall be written in simple and plain language and shall list, in a check-off format, each of the following statements:

101.648(4)(a) (a) The person’s religious beliefs and the established tenets or teachings of the religious sect of which the person is a member conflict with one or more dwelling construction standards.

101.648(4)(b) (b) The dwelling for which the waiver is requested will be used solely as a residence for the person or members of the person’s household.

101.648(4)(c) (c) The waiver is requested based upon the long-established tenets and teachings of the religious sect of which the person is a member and the religious sect did not establish these tenets and teachings solely to avoid compliance with dwelling construction standards.

101.648(4)(d) (d) The person agrees to modify the dwelling for which the waiver is requested to comply with dwelling construction standards if the person ceases to adhere to the tenets or teachings of the religious sect of which the person is a member and upon which the waiver is requested.