BRUNSWICK COUNTY CODE ADMINISTRATION
75 Courthouse Drive, Building I
Bolivia, NC 28422
Phone: 910-253-2021
Fax: 910-253-2024
AFFIDAVIT OF WORKERS' COMPENSATION COVERAGE
N.C.G.S.
§
87-14
The undersigned applicant for Building Permit Number ______________ being the
Contractor
Owner
Officer/Agent of the Contractor of 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 (1) or more subcontractor(s) and have obtained worker's compensation insurance
covering them,
has/have one (1) or more subcontractor(s) who has/have their own policy of worker'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 Central Permitting
Department issuing the permit may require certificates of coverage of worker's 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:
Sworn and subscribed to me this _______________ day of _____________, 20___
____________________ My commission expires ____________ day of ___________, 20___
Official Notary Public Seal
