HomeMy WebLinkAboutBLD2009-00479 WORKER COMP.TIFV �
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Affidavit of Worker's Compensation Coverage
and State Privilege License Requirements
N.C.G.S. 87 -14
The undersigned applicant for Building Permit #
the
BLD2009 -00479 being
Unlicensed Contractor _ Owner _ Officer /Agent of the Contractor
do hereby aver under penalties of perjury that the person(s), firm(s), or corporation(s)
performing the work set forth in the permit:
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has/ have three (3) or more employees and have obtained workers compensation
insurance to cover them,
has/ have one or more subcontractor(s) and have obtained worker's compensation
Insurance covering them,
has/ have one or more subcontractor(s), who has/ have no employees and has waived in
writing their right to coverage by their contractor or have their own policy of workers
comp ensa i v nn g a ves,
has/ have not more than two (2) employees and no subcontractors
has renewed Contractors License
has/ have applied for permit where the cost is under $30,000 and I am therefore exempt
from Licensed General Contractor requirements specified by G.S. 87 -14,
has/ have applied for permit under owner exception to the licensing requirements
madating occupancy of the premise for 12 months following completion of the project,
while working on the project for which this permit is sought.
It is understood that the Inspections Department issuing the permit may require certificates of
coverage and / or waivers of workers compensation insurance coverage prior to issuance of the
permit and at any time during the permitted work from any person, firm, or corporation carrying out
the work. SIGNATURES ARE TO BE WITNESSED BY INSPECTIONS PERSONNEL OR
NOTARIZED.
Firm Nam
By:
A
Title:
Sworn to and subscribed before me this day of
Signature of Notary
Date:
NEI
Offical Seal
My Commission Expires , 20