Chapel Hill, NC · Orange County
Workers' Compensation Affidavit
Building permit applicants use this affidavit to report workers’ compensation coverage for people performing work on the permitted project.
What this form is
This affidavit accompanies a building permit application and records the workers’ compensation coverage status of people performing the permitted work. The applicant identifies their relationship to the project and selects the statement that applies to employees and subcontractors. The form also requests the firm name, signer’s name, printed name, date, and title.
Who needs it
A contractor, property owner, or their officer or agent applying for a Chapel Hill building permit uses this affidavit.
How to submit it
The form lists Building & Development Services at 405 Martin Luther King Jr Blvd, Chapel Hill, and provides [email protected] and [email protected] as email contacts.
About notarization
This document is signed and dated without a notary; the signer attests under penalties of perjury that the information is true and valid.
How to submit this form
- 1
Download The Affidavit
Download the Workers' Compensation Affidavit PDF.
- 2
Complete The Form
Identify the building permit applicant’s role and select the workers’ compensation coverage statement that applies.
- 3
Enter Applicant Details
Provide the firm name, signature, printed name, date, and title.
- 4
Submit The Form
Use the Building & Development Services address or email contacts listed on the form.
Frequently asked questions
- What does the Workers' Compensation Affidavit report?
- It records workers’ compensation coverage information for people performing work on the project for which a building permit is sought.
- Who completes this affidavit?
- The building permit applicant completes it as a contractor, property owner, or officer or agent of the contractor or owner.
- Do I need a notary for the Workers' Compensation Affidavit?
- No. The document has no notary block; the signer signs and dates it and attests under penalties of perjury that the information is true and valid.
- How do I submit the Workers' Compensation Affidavit?
- The form lists Building & Development Services at 405 Martin Luther King Jr Blvd and provides [email protected] and [email protected] as email contacts.
Need something notarized?
This Workers' Compensation Affidavit doesn’t need a notary — but if you have another Chapel Hill form that does, a commissioned online notary can help.