STAT
E OF NORTH CAROLINA OWNER EXEMPTION AFFIDAVIT
PURSUANT TO G.S. 87-14 (a) (1)
COUNTY OF ______________________
___________________________ Inspection Department
Parcel Identification Number and address where the building is to be constructed: PIN _______________________
Add
ress_____________________________________________________________________________________
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 G.S. 87-1(b)(2) by initialing the relevant provision in paragraph 1
and initialing paragraphs 2-5 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;
OR
______ I am legally authorized to act on behalf of the firm or corporation that 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, Chapter 87
of the General Statues of North Carolina.
3. ______ I will be on site regularly during construction and 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 by executing this licensing exemption AFFIDAVIT pursuant to G.S. 87-1(b)(2), 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 offered for rent, lease or sale.
5. ______ I understand a copy of this AFFIDAVIT will be transmitted to the North Carolina Licensing Board for
General Contractors for verification 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 if the North Carolina Licensing Board
for General Contractors determines I am not entitled to claim this exemption the building permit issued for the
construction or alteration specified herein shall be revoked pursuant to G.S 153A-362 or G.S. 160A-422.
________________________________________________________ ________________________________
(Signature of Affiant) (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)
(NOTE: It is a class F felony to willfully commit perjury in any affidavit taken pursuant to NC G.S. 14-209)
