The undersigned applicant for Building Permit # being the
Contractor Owner Officer/Agent of the Contractor Owner
Do hereby assert under penalties of perjury that the person(s), firms(s) or corporation(s) performing the
work set forth in the permit:
has/have three (3) or more employees and have obtained worker’s compensation insurance to cover
them,
has/have one or more subcontractor(s) and have obtained workers’ compensation insurance covering
them,
has/have one or more subcontractor(s) who has/have their own policy of workers’ 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 Inspection
Department issuing the permit may require certificates of coverage of workers’ 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:
§ 87-14. Regulations as to issue of building permits.
Any person, firm or corporation, upon making application to the building inspector or such other authority of any incorporated city, town or
county in North Carolina charged with the duty of issuing building or other permits for the construction of any building, highway, sewer, grading or
any improvement or structure where the cost thereof is to be thirty thousand dollars ($30,000) or more, shall, before he be entitled to the issuance of
such permit, furnish satisfactory proof to such inspector or authority that he or another person contracting to superintend or manage the construction
is duly licensed under the terms of this Article to carry out or superintend the same, and that he has paid the license tax required by the Revenue Act
of the State of North Carolina then in force so as to be qualified to bid upon or contract for the work for which the permit has been applied, and that
he has in effect Workers' Compensation insurance as required by Chapter 97 of the General Statutes; and it shall be unlawful for such building
inspector or other authority to issue or allow the issuance of such building permit unless and until the applicant has furnished evidence that he is
either exempt from the provisions of this Article or is duly licensed under this Article to carry out or superintend the work for which permit has been
applied; and further, that the applicant has paid the license tax required by the State Revenue Act then in force so as to be qualified to bid upon or
contract for the work covered by the permit; and further, that the applicant has in effect Workers' Compensation insurance as required by Chapter
97 of the General Statutes. Any building inspector or other such authority who is subject to and violates the terms of this section shall be guilty of a
Class 3 misdemeanor and subject only to a fine of not more than fifty dollars ($50.00). (1925, c. 318, s. 13; 1931, c. 62, s. 4; 1937, c. 429, s. 7; 1949,
Town of Burgaw Inspections Department
Affidavit of Workers’ Compensation Coverage
N.C.G.S. 87-14
109 N. Walker St. ∙ Burgaw ∙ NC ∙ 28425 ∙ 910-259-6644
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