Hope Mills, NC · Cumberland County
Affidavit of Workers' Compensation Coverage
Contractors, owners, or their officers or agents complete this affidavit when applying for a Hope Mills building permit to report workers' compensation coverage.
What this form is
This affidavit accompanies an application for a Hope Mills building permit and records the workers' compensation coverage status of the people or businesses doing the permitted work. The applicant identifies whether there are three or more employees, subcontractors with coverage, or no more than two employees and no subcontractors. It also requests the firm name, signer’s name and title, and date.
Who needs it
A building permit applicant who is a contractor, owner, or their officer or agent completes the affidavit for the work covered by the permit.
How to submit it
The form identifies the Inspection Department as issuing the building permit and says it may require insurance coverage certificates. Submit the affidavit with the permit application to the Inspection Department.
About notarization
This affidavit is signed without a notary; the signer makes the statement under penalties of perjury and signs and dates it.
How to submit this form
- 1
Download The Affidavit
Download the Hope Mills Affidavit of Workers' Compensation Coverage PDF.
- 2
Complete The Coverage Statement
Identify the workers' compensation coverage situation for the people or businesses performing the permitted work.
- 3
Enter Signer Details
Provide the firm name, signer's name and title, and date; sign the statement under penalties of perjury.
- 4
Submit With The Permit Application
Submit the completed affidavit with the building permit application to the Inspection Department.
Frequently asked questions
- Do I need a notary for the Workers' Compensation Coverage Affidavit?
- No. The affidavit is signed without a notary, but the signer makes the statement under penalties of perjury and must sign and date it.
- Who completes this affidavit?
- The building permit applicant completes it as a contractor, owner, or officer or agent of the contractor or owner.
- What information does the affidavit request?
- It asks the applicant to identify the workers' compensation coverage situation for the permitted work and provide the firm name, signer’s name and title, and date.
- How do I submit the affidavit?
- Submit it with the building permit application to the Inspection Department, which the form identifies as issuing the permit.
Need something notarized?
This Affidavit of Workers' Compensation Coverage doesn’t need a notary — but if you have another Hope Mills form that does, a commissioned online notary can help.