100 N King St
Hendersonville, NC 28792
Owner Exemption Phone: 828-697-4830
STATE OF NORTH CAROLINA
Henderson County
Parcel Identification Number and address where the building is to be constructed: PIN_________________
Address:________________________________________________________________________________
Type of Construction: ___Residential ___Commercial ____Industrial ____Other
Intended use after completion (e.g. Personal Residence):_________________________________________
Building permit number associated with this application:_________________________________________
I,_________________________________________________ ( )_______________________________
(Print Full Name) (Phone Number)
Hereby claim exemption from licensure under by initialing numbers 1-4 below attesting to the following:
1. ______I certify I am the owner of the property set forth above on which a building is to be constructed or
altered and for which application for a building permit is hereby made.
2. ______I will personally perform all work concerning the trade(s) checked below.
3. ______I will be present for all for the inspections for the trade(s) checked below.
4. ______I understand I am required by law to occupy the building for which the licensing exemption is granted for
twelve months after completion, during which time it may not be rented, leased, sold or gifted.
________________________________________________________ ____________________________
(Signature of Affidavit) (Date)
Sworn or affirmed and subscribed before me this the ______day of________________,20______________
__________________________________________________
(Signature of Notary Public)
__________________________________________________ (Notary Stamp or Seal)
(Printed Name of Notary Public)
MECHANICAL PLUMBING ELECTRICAL
OWNER EXEMPTION AFFIDAVIT OWNER EXEMPTION AFFIDAVIT OWNER EXEMPTION AFFIDAVIT
PURSUANT TO G.S. 87-21(a) (5) PURSUANT TO G.S. 87-21 (a) (5) PURSUANT TO G.S. 87-43 & 87-43.1
