STATE OF NORTH CAROLINA
OWNER EXEMPTION AFFIDAVIT
PURSUANT TO G.S. 87-14(a) (1)
COUNTY OF JOHNSTON
TOWN OF CLAYTON PERMITS & INSPECTIONS DEPARTMENT
Address and Parcel Identification of Real Property Where Building is to be Constructed or Altered:
______________________________________________________________________________________
I, ____________________________________________________________________________________
(Print Full Name)
hereby claim an exemption from licensure under G.S. 87-1(b) (2) by initiating the relevant provision in
paragraph 1 and initiating paragraphs 2-4 below and attesting to the following:
1. _____ I certify that I am the owner of the property set forth above on which this building is to
be constructed or altered;
OR
_____I am legally authorized to act on behalf of the firm or corporation which is constructing
or altering this building on the property owned by the firm or corporation as set forth
above (name of firm or corporation :________________________________________);
2. ______I will personally superintend and manage all aspects of the construction or alteration of
the building and that duty will not be delegated to any person not duly licensed under the terms
of Article 1 of Chapter 87 of the General Statutes of North Carolina;
3. ______I will be personally present for all inspections required by the North Carolina State
Building Code, unless the plans for the construction or alteration of the building were drawn
and sealed by an architect licensed pursuant to Chapter 83A of the General Statutes of North
Carolina;
4. ______I understand that a copy of this AFFIDAVIT will be transmitted to the North Carolina
Licensing Board for General Contractors for verification that I am validly entitled to claim an
exemption under G.S. 87-1(b) (2) for the building construction or alteration specified herein.
I further understand that, if the North Carolina Licensing Board for General Contractors
determines that I was not entitled to claim this exemption, the building permit issued for the
building construction or alteration specified herein shall be revoked pursuant to G.S. 153A-
362 or G.S. 160A-422.
_____________________________________________ __________________
(Signature of Affiant) Date
Sworn to (or affirmed) and Subscribed before me
this the ___day of __________________, 20___
__________________________________
Signature of Notary Public
__________________________________
Printed Name of Notary Public
My Commission Expires: _____________ (Notary Stamp or Seal)
(NOTE: It is a Class F felony to willfully commit perjury in any affidavit taken pursuant to
law G.S. 14-209)
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