Workers’ Compensation Exemption Form – Wake County, NC

The Workers’ Compensation Exemption Form, printed as the Affidavit of Workers’ Compensation Exemption Form, is a sworn statement used with a Wake County building permit in which the contractor attests to having not more than two employees on the permitted project.

The form is headed with North Carolina General Statutes 87 and 97. The signer declares, under penalties of perjury, that the person(s), firm(s) or corporation(s) performing the work set out in the permit have not more than two employees while working on the project for which the permit is sought.

It identifies the project address, the contractor's address, whether the contractor is licensed (with the license number) or unlicensed, the firm name, who completed the form, that person's title, and a signature and date.

Wake County Planning, Development and Inspections publishes the form. The county's page on revising permits says a new certificate of insurance or Workers’ Compensation Exemption Form is required for each change of General Contractor on a permit, so the form is an alternative to proof of insurance, not an addition to it. The form is a statement about the contractor's employee count. It is not a permit and does not approve any work.

The main group is contractors, licensed or unlicensed, who appear on a Wake County building permit and whose crew has not more than two employees on the project. The affidavit is the statement that this is the case.

The form must be signed by one of these people, whichever matches the contractor named on the building permit:

• the owner of the proprietorship;
• a partner in the partnership;
• an officer of the corporation;
• the manager of the L.L.C.

Because the signer swears that the workers on the project number no more than two, the form fits only where that statement is true. The form says nothing about who else may sign for the contractor, so no one outside the four roles above should sign it.

Per the county's page on revising permits, a new certificate of insurance or Workers’ Compensation Exemption Form is required each time the General Contractor on a permit changes.

The form is completed when a permit is sought for a project, because its text refers to the project "for which this permit is sought." No separate due date is printed on it.

The county's page on revising permits adds one triggering event: a new certificate of insurance or Workers’ Compensation Exemption Form is required for each change of General Contractor. If the contractor on your permit changes, the new contractor needs its own form.

Only permit applicants, contractors and property owners may modify contacts on a permit, according to the same page.

The form prints no mailing address, portal or email, so confirm the channel with Wake County Planning, Development and Inspections when you submit it for your permit.

What the county's page on revising permits says that relates to this form:

• Change of General Contractor: a new certificate of insurance or Workers’ Compensation Exemption Form is required for each change.
• Contact changes on a permit: email a completed Add, Remove or Change Contacts Form to [email protected]. Only permit applicants, contractors and property owners are authorized to modify contacts.

Sign and date the affidavit before you submit it; the signer must be the owner, partner, officer or manager who appears as the contractor on the building permit. FillingPDF lets you fill out and download the PDF; submission follows the county's channels above.