HomeMy WebLinkAboutBLDR-3-12-25637 WORKER'S COMPENSATION.tif CATAWBA COUNTY PERMIT
BUILDING (R)
8 z 5M BLDR - 3 - 12 - 25637
New Building
AFFIDAVIT OF WORKER'S COMPENSATION COVERAGE
AND STATE PRIVILEGE LICENSE REQUIREMENTS
N.C.G.S.87 -14
The undersigned applicant for Building Permit # BLDR -3 -12 -25637 being the
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:
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 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/have not more that two (2) employess and no subcontractors.
has renewed Contractor 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 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 and/or 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 OR NOTARIZED.
FIRM NAME: /� 1 � 1102 * 4 e � , 9 G( a 1 Ll.(-
BY (PRINT): TITLE:
SIGNATURE: DATE: l L
SWORN TO AND SUBSCRIBED BEFORE ME THIS DAY OF , 20
SIGNATURE OF NOTARY:
MY COMMISSION EXPIRES , 20 OFFICL4L SE,4L
permit 03/06/2012 15:28 Page 2 of 2