Miscellaneous Permit Application

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NC 28512
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PERMIT APPLiCATION
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ADDRESS
PROJECT ADDRESS
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CONTRACTOR
CONTRACTOR
INFORMATION
NAME
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ADDRESS
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will
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TOTAL PBRMIT FEE
u rmm DEP
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DEP
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CHECK
TO
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PPLIC TIOW FOR BUILDING PEm ITn
G
NER L
CONTIWUED
CONTRACTOR
NAME
PHONE NO
ADDRESS
STATE LICENSE
CLASSIFICATION
ELECTRICAL
CONTRACTOR
NAME
PHONE NO
ADDRESS
STATE
LICENSE
CLASSIFICATION
PLUMBING CONTRACTOR
NAME
PHONE NO
ADDRESS
STATE
LICENSE
CLASSIFICATION
MECHANICAL
CONTRACTOR
NAME
PHONE NO
ADDRESS
STATE
LICENSE
CLASSIFICATION
INSULATION
CONTRACTOR
NAME
PHONE NO
ADDRES S
STATE
LICENSE
CLASSIFICATION
DESIGN
PROFESSIONAL
NAME
PHONE
ADDRESS
STATE
LICENSE
CLASSIFICATION
NO
APPENDIX D
AFFIDAVIT OF WORKERS
COMPENSATION COVERAGE
N C G S
The
87
undersigned applicant for Building Permit
4
being the
Contractor
Owner
Officer
do
Agent
hereby aver under penalties ofpeIjury
in the
of the Contractor
that the person
permit
haslhave three 3
haslhave
covering
one or more
haslhave one
themselves
haslhave
or more
employees
subcontractor
or more
2
Owner
firm
s
or
corporation
and have obtained workers
s
performing
s
employees
who has have their
and
no
the work set forth
compensation insurance to cover them
and have obtained workers compensation insurance
subcontractor
not more than two
while
s
s
or
own
policy
covering them
of workmen
s
compensation
subcontractors
working on the project for which this permit is sought It is understood that the Inspection Department
the permit may require certificates of coverage of workers compensation insurance prior to issuance of the
and at any time
during the permitted work from any person firm or corporation carrying out the work
issuing
permit
Firm name
By
Title
Date
NC Administration
Enforcement
@
139