950 Steeple Square Court
Knightdale, NC 27545
(v) 919-217-2241
(f) 919-217-2249
www.knightdalenc.gov
DEVELOPMENT SERVICES DEPARTMENT
T O W N O F K N I G H T D A L E
TOWN OF KNIGHTDALE / WAKE COUNTY BUILDING INSPECTIONS
AFFIDAVIT OF WORKERS' COMPENSATION COVERAGE
NORTH CAROLINA GENERAL STATUTES 87 AND 97
The undersigned applicant for Building Permit Number ______________, being the:
Unlicensed Contractor Owner Officer/Agent of the Contractor/Owner
License #:
do hereby positively declare under penalties of perjury that the person(s), firm(s), or corporation(s) performing the work
set forth in the permit (check one):
has/have three (3) or more employees and have obtained workers' compensation insurance to has/have one (1)
or more subcontractor(s) and have obtained workers' compensation insurance to cover them,
has/have one (1) or more subcontractor(s), who has/have no employees and have waived in writing their right to
coverage by their contractor or if required have their own policy of workers' compensation covering themselves,
has/have not more than two (2) employees and no subcontractors,
has/have paid the licensing tax for General Contractors as required by the Revenue Act of the State of NC,
has/have applied for permit where the project cost is under $30,000 and I am therefore exempt from Licensed
General Contractor requirements specified by G.S. 87-14,
has/have applied for permit under owner exception to the licensing requirements by mandating occupancy of the
premises for 12 months following completion of the project,
while working on the project for which this permit is sought. It is understood that the Wake County Inspections Division
may require certificates of coverage and/or waivers of workers' compensation insurance coverage prior to issuance of the
permit. This document must be signed by the owner of a proprietorship, partner in a partnership, officer or manager of a
LLC, or property owner (as the case may be) appearing as the contractor on the building permit.
NOTE: Signature to be either witnessed by a representative of the Town of Knightdale or Notarized.
FIRM/PROPERTY OWNER NAME:
OFFICER/PARTNER/FIRM OWNER:
TITLE: SIGNATURE: DATE:
WITNESSED: PLAN REVIEWER
Sworn to and subscribed before me this ______ day of _____________________, 20_______. INITIALS ___________
NOTARIZED:
______________________________ (SEAL) My Commission
Signature of Notary Expires on ___________________, 20_______.
