10/17/2017
BRUNSWICK COUNTY CODE ADMINISTRATION
75 Courthouse Drive, Building I
Bolivia, NC 28422
Phone: 910-253-2021
Fax: 910-253-2024
CHANGE OF CONTRACTOR AFFIDAVIT
Date: _____________
I, Owner Agent _________________________ of _________________________ for the property located at
(Name of Company)
____________________________ have released _____________________ of _____________________ as
(Address) (Contractor) (Company)
__________________ contractor of this project, reference release permit number __________________.
(Trade Name)
I will be acting as my own contractor.
I have hired ____________________________ as my new contractor and understand that a new permit will
have to be issued in their name for this job location.
New Permit Number: _____________________
Other, please explain ______________________________________________________________________
Fee Paid
This document must be signed by the person appearing as owner on the permit. Signature must be notarized.
___________________________________________ or ____________________________________________
(Owner Signature) (Agent Signature/Title)
Sworn to and subscribed before me this ____________ day of ______________, 20_____
__________________________
(Notary Signature)
My commission expires ___________, 20_____
