Fill out Affidavit of Workers' Comp Coverage form

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Affidavit of Workers’ Compensation Coverage N.C.G.S. 87-14

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The undersigned applicant for Building Permit #
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being the
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Do hereby aver under penalties of perjury that the person(s), firm(s) or corporation(s) performing the work set forth in the permit:
Do hereby aver under penalties of perjury that the person(s), firm(s) or corporation(s) performing the work set forth in the permit:
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 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.
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Firm Name (if applicable)
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Submitted by
Submitted by
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Placing your name in the signature block has the same effect as signing your name in pen on a written document.
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