City of Gastonia Building Permits & Inspections Department

codeenf@cityofgastonia.com

PO Box 1748 150 S York Street Gastonia, NC 28053

704-866-6729 press 3

APPENDIX D

AFFIDAVIT OF WORKERS' COMPENSATION COVERAGE

N.C.G.S. §87-14

The undersigned applicant being the:

Select All That Apply:

Contractor

Owner:

Officer/Agent of the Contractor or Owner

Contractor:

Owner:

Officer/Agent of the Contractor or Owner:

Do hereby aver under penalties of perjury that the person(s), firm(s) or corporation(s) performing the work set forth in the permit:

Select all that apply:

has/have three (3) or more employees and have obtained workers' compensation insurance to cover them,

has/have one ore more subcontractor(s) and have obtained workers' compensation insurance to cover them,

has/have one ore more subcontractor(s) who has/have their own policy of workmen's 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 certficates 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:

Primary Phone Number

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Receipt

You will be provided with a Receipt upon submission.