APPENDIX D

AFFIDAVIT OF WORKERS' COMPENSATION COVERAGE N.C.G.S. § 87-14

The undersigned applicant for Building Permit # _______ being the __________________________ Contractor __________________________ Owner

____________________________Officer/Agent of the Contractor or Owner

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 workers' compensation insurance covering them,

_____ has/have one or more subcontractor(s) who has/have their own policy of workmen's compensation

covering themselves,

_____ has/have not more than two (2) employees and no subcontractors,

while working on the project for which this permit is sought. It is understood that the Inspection Department issuing the permit may require certificates of coverage of workers' compensation insurance prior to issuance of the permit and at any time during the permitted work from any person, firm or corporation carrying out the work.

Firm name: _____________________________

By: ____________________________________

Title:________________________________________Date:_______________________________________

NC Administration & Enforcement ®