HomeMy WebLinkAboutBLDC-2-12-24738 AFFIDAVIT OF WORKER'S COMPENSATION FORM.tif Feb 161210:04a MICHAEL GOODELLE 8662966706 p•3
CATAWBA COUNTY PERMIT
BUILDING (C)
\� BLDC -2 -12 -24738
Alteration
AFFIDAVIT OF WORKER'S COMPENSATION COVERAGE
AND STATE PRIVILEGE LICENSE REQUIREMENTS
N.C.G.S.87 -14
The undersigned applicant for Building Permit # BLDC -2 -12 -24738 being the
Unlicensed Contractor Owner X OfficeriAgent 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:
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.
Y ,, has,'izave one or more contractor(s) who has•'have no employees and has waived and has waived in writing their right to
coverage by their contractor or have their own policy or worker's compensation covering themselves
has,liave not Snore that two (2) employees and no subcontractors.
has renewed Contractor License.
haslhave applied for permit where the cost is under 530,000 and 1 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 mandating occupancy of the premise
for 12 months following the completion of the project, while working on the project for which the permit is sought,
It is understood that the Inspections Department issuing the permit may require certificates of coverage andror waivers of worker
compensation insurance coverage prior to issuance of the permit and at any time during the permitted work for any person. firm or
corporation carrying out the work.
SIGNATURES ARE TO BE WITNESSED BY INSPECTIONS PERSONNEL ORNOTARIZED.
FIRM NAME ��,Q�lirti c C �:,.i;� c;Zaa Si�tai�c..�S LZC-
BY (PRINT): # -� „` i u $ TITLE: 1ilrJ.t C ��.SL 15s�t :tlL
SIGNATURE: DATE: lZ
SWORN TO AND SUBSCRIBED BEFORE ME THIS DAY OF 1 20
SIGNATURE OF NOTARY:
MY COMMISSION EXPIRES 20
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