Carolina Shores, NC · Brunswick County
Affidavit of Workers’ Compensation Coverage
Contractors or owners submit this affidavit for a building permit to state how workers’ compensation coverage applies to the people performing the permitted work.
What this form is
This affidavit accompanies a building permit application and records the applicant’s statement about workers’ compensation coverage for employees and subcontractors performing the work. It asks for the permit number, the applicant’s relationship to the contractor or owner, the applicable coverage statement, and the firm name, signer, title, and date. The Inspection Department may require certificates of insurance coverage before issuing the permit or during permitted work.
Who needs it
A contractor, owner, or their officer or agent applying for a building permit submits this affidavit about workers’ compensation coverage.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This document is signed without a notary; the signer makes an averment under penalties of perjury and signs and dates the affidavit.
How to submit this form
- 1
Download The Affidavit
Download the Workers’ Compensation Coverage Affidavit.
- 2
Complete The Affidavit
Enter the building permit number, applicant role, applicable coverage statement, firm name, signer, title, and date.
- 3
Gather Coverage Certificates
The Inspection Department may require certificates of workers’ compensation insurance coverage before permit issuance or during permitted work.
- 4
Submit To The City
Submit the affidavit to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- Do I need a notary for the Workers’ Compensation Coverage Affidavit?
- No. The document has no notary block; the signer makes an averment under penalties of perjury and signs and dates it.
- Who completes this affidavit?
- The applicant for a building permit may be the contractor, owner, or an officer or agent of the contractor or owner.
- What information does the affidavit ask for?
- It asks for the building permit number, the applicant’s role, a workers’ compensation coverage statement, the firm name, and the signer’s name, title, and date.
- How do I submit the affidavit?
- Submit it to the city department named on the form; check the city website for current contact details.