Chautauqua, NY · Chautauqua County
Workers’ Compensation Exemption Affidavit
This affidavit lets an owner of an owner-occupied one- to four-family residence explain why workers’ compensation coverage proof is not required for a building permit.
At a glance
- Issued by
- City of Chautauqua · Chautauqua, Chautauqua County, New York
- Notarization
- Required: sign this form in front of a notary before filing it.
- Official source
- townofchautauqua.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
- licensed online notary
- ~15 min average
- Notarized PDF emailed
What you’ll need
- Government-issued photo ID
- Webcam-enabled device (laptop or phone)
- This form, ready to upload as a PDF
What this form is
The BP-1 affidavit is for an owner applying for a building permit for an owner-occupied one- to four-family residence, including a condominium. The owner selects the reason they are exempt from providing specific proof of workers’ compensation coverage and makes related commitments if paid work reaches 40 hours or more per week. Once notarized, the form serves as an exemption for workers’ compensation and disability benefits insurance coverage and is provided to the government entity issuing the permit.
Who needs it
An owner applying for a building permit for an owner-occupied one- to four-family residence who claims an exemption from showing specific proof of workers’ compensation coverage needs this affidavit.
Why it needs a notary
The form contains a sworn-to jurat block, and the homeowner signing the affidavit must swear to it before a notary public.
How to get this notarized
- 1
Download The BP-1 Form
Get the Workers’ Compensation Exemption Affidavit from the Town of Chautauqua form source.
- 2
Fill In The Affidavit
Enter the requested homeowner and property details, and select the exemption reason that applies.
- 3
Book An Online Notary
Schedule a remote session with a commissioned online notary and have your identification ready.
- 4
Sign On Video
Appear by video, swear to the affidavit, and sign when instructed by the notary.
- 5
Submit To The Permit Issuer
Provide the notarized BP-1 to the government entity issuing your building permit.
Preview the form
The blank PDF straight from Chautauqua. Look it over, then upload your filled copy to start the notary session.
You’ll need ID and a webcam.
A licensed online notary will join you on video, verify your government-issued ID, witness your signature, and apply their seal. You’ll receive the notarized PDF by email when the session ends.
Frequently asked questions
- How do I notarize the BP-1 affidavit online?
- Complete the affidavit, then book a session with a commissioned online notary. Sign and swear to the affidavit during the video session, and submit the notarized form to the government entity issuing your building permit.
- Do I need to sign the affidavit in front of a notary?
- Yes. The form includes a sworn-to block for a notary public. The homeowner who makes the affidavit must swear to it before the notary and sign as directed.
- Can I use this affidavit if I hire workers?
- The form lists exemption options, including hiring or paying individuals for less than 40 aggregate hours per week when the stated homeowners insurance condition is met. Read the form and confirm your circumstances with the permit-issuing government entity.
- Can I complete this form with a remote online notary?
- New York authorizes remote online notarization by a commissioned online notary. Check that the government entity issuing your building permit will accept the notarized form in your circumstances; confirm with the city, town or village if unsure.
Workers’ Compensation Exemption Affidavit in other New York cities
Each city publishes its own version of this form. Pick the city where you’re filing.