Burgaw, NC · Pender County
Affidavit of Workers’ Compensation Coverage
Contractors or owners applying for a building permit use this affidavit to state their workers’ compensation coverage status for the work covered by the permit.
What this form is
This affidavit accompanies a building permit application and asks the applicant, as contractor or owner, to identify the workers’ compensation coverage arrangement for people performing the permitted work. The signer selects the applicable statement about employees and subcontractors, then provides the firm name, signature, title, and date. The Inspection Department may require certificates of coverage before issuing the permit and during the permitted work.
Who needs it
A contractor, owner, or contractor’s officer or agent applying for a Burgaw building permit completes the affidavit about workers’ compensation coverage.
How to submit it
Return the completed affidavit to the Town of Burgaw Inspections Department, 109 N. Walker St., Burgaw, NC 28425; the form lists 910-259-6644.
About notarization
This document is signed without a notary; it includes an assertion under penalties of perjury, and the signer completes the signature and date fields.
How to submit this form
- 1
Download The Affidavit
Download the fillable Workers’ Compensation Coverage Affidavit PDF.
- 2
Complete The Form
Select the statement that describes the employees and subcontractors on the permitted work, then enter the firm name, title, signature, and date.
- 3
Gather Coverage Certificates If Required
The Inspection Department may require certificates of workers’ compensation coverage before permit issuance or during the permitted work.
- 4
Submit To The Inspections Department
Return the completed affidavit to the Town of Burgaw Inspections Department at 109 N. Walker St., Burgaw, NC 28425.
Frequently asked questions
- What is the Workers’ Compensation Coverage Affidavit for?
- It records the applicant’s assertion about workers’ compensation coverage for employees and subcontractors performing work covered by a building permit.
- Who completes this affidavit?
- The building permit applicant completes it as the contractor, owner, or an officer or agent of the contractor or owner.
- Do I need a notary for the Workers’ Compensation Coverage Affidavit?
- No. The document has no notary block; the signer completes the signature and date fields. It does include an assertion under penalties of perjury.
- How do I submit the Workers’ Compensation Coverage Affidavit?
- Return it to the Town of Burgaw Inspections Department at 109 N. Walker St., Burgaw, NC 28425. The form lists 910-259-6644.
Need something notarized?
This Affidavit of Workers’ Compensation Coverage doesn’t need a notary — but if you have another Burgaw form that does, a commissioned online notary can help.