2. APPENDIX D

   Affidavit of Workers' compensation Coverage N.C.G.S. § 87-14

4. Building Permit #:*
6. The undersigned applicant of the aforementioned Building Permit # being the:

   1. Contractor
   2. Owner
   3. Officer/Agent of the Contractor or Owner
8. do hereby waiver under penalties of perjury that the person(s), firm(s) or corporation(s) performing the work set forth in the permit:

   1. has/have three (3) or more employees and have obtained workers’ compensation insurance to cover them,
   2. has/have one or more subcontractor(s) and have obtained workers’ compensation insurance to cover them,
   3. has/have one or more subcontractor(s) who has/have their own policy of workers’ compensation covering themselves,
   4. has/have not more than two (2) employees and no subcontractors,

10. 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.

12. Firm Name:*
13. Date:*
    Date:
15. Signed By:*

    Please print the name and sign in front of a notary.

16. Title:
Leave This Blank:


17. Print Only

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