Form No. 5. (Revised Effective March 1, 1999)
NORTH CAROLINA OFFICIAL WAIVER OF MINIMUM REQUIREMENTS FOR THE
CONTROL OF SUBTERRANEAN TERMITES IN EXISTING STRUCTURES
Property Owner: Agent:
Address: Address:
City: City:
Location of Property, if different from above: Date of Contract:
Type of Construction
Basement: Crawl-Space: Slab: Combination:
Before signing this form you should read and understand each of the treatment specifications indicated below. These specifications are
based on the minimum requirements of the N.C. Structural Pest Control Committee.
The items checked below apply to the structure to be treated and will not be performed in treating the property listed above. Any item checked
below must be explained on the right adjacent to the item checked on the left.
I. Mechanical Alterations/Sanitation: Explanation and location of item(s) waived :
‘ A. Provide access openings to permit inspection of all basement and _________________________________________________________________
crawl-space areas.
‘ B. Remove all wood and cellulose materials , such as stumps, form boards _________________________________________________________________
and construction debris, contacting soil in all crawl-space areas.
‘ C. Provide required clearance between soil and wood floor joists, girders _________________________________________________________________
and subsills.
‘ D. Remove all visible tubes or tunnels on the foundation and other _________________________________________________________________
structures below the sill line.
‘ E. Remove all wooden contacts between the building and soil both outside _________________________________________________________________
and inside except those which are pressure treated.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
II. Foundation Treatment: _________________________________________________________________
‘ F. Drill and treat with a termiticide all voids in multiple masonry walls within
4 feet of any evidence of termites.
‘ G. Drill and treat with a termiticide all voids in multiple masonry pillars,
pilasters, chimneys, and step buttresses within 4 feet of any evidence of
termites. _________________________________________________________________
‘ H. Drill and treat with a termiticide voids in porch walls.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
III. Slab Treatment: _________________________________________________________________
‘ I. Drill and treat all concrete slab porches as required.
‘ J. Where concrete slabs other than porches, such as walkways, carports _________________________________________________________________
and patios, prevent trenching soil adjacent to foundation elements, drill
slab and treat soil beneath slab.
‘ K. Treat soil with a termiticide beneath floor slabs, such as garages,
storage rooms and interior floor slabs.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
IV. Soil Treatment: _________________________________________________________________
‘ L. Treat soil with a termiticide adjacent to all foundation elements, pipes
and other utility conduits both inside and outside the foundation wall. (If
slabs adjacent to the foundation wall prevent trenching, see “Slab _________________________________________________________________
Treatment J.” above.)
‘ M. Trench and treat soil with a termiticide to a depth below and under the _________________________________________________________________
edge of stucco on wood or similar type material.
_________________________________________________________________
_________________________________________________________________
V. Service Agreement Information:
This treatment is ________ is not ________ covered by a service agreement (one must be checked). If a service agreement is to be issued, a copy
is attached to these specifications.
Company: License No.: Signature of Licensee or Company Representative:
PROPERTY OWNER/AGENT: DO NOT SIGN THIS FORM IF YOU DO NOT UNDERSTAND IT OR IF YOU HAVE ANY QUESTIONS REGARDING THE QUALITY
OR EXTENT OF TREATMENT TO BE PERFORMED. DO NOT SIGN A BLANK FORM.
Signature of Owner / Agent: Date:
