Livingston, NY · Columbia County
Homeowner Workers’ Compensation Exemption Form
Homeowners of qualifying owner-occupied residences submit this affidavit to claim an exemption from workers’ compensation coverage proof when applying for a building permit.
What this form is
This affidavit lets an eligible homeowner of a one- to four-family owner-occupied residence document why specific proof of workers’ compensation coverage is not required for a building permit. It asks the homeowner to select an exemption basis, identify the property, and sign and date the form. Homeowners hiring or paying workers for 40 or more aggregate hours per week must use the coverage or proof options described in the document instead.
Who needs it
A homeowner listed as general contractor on a building permit may use this form for a qualifying owner-occupied residence if one of the listed exemption conditions applies.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This document is signed without a notary; the signer just signs and dates it.
How to submit this form
- 1
Download The Form
Download the Homeowner Workers’ Compensation Exemption Form PDF.
- 2
Complete The Affidavit
Select the applicable exemption basis and provide the requested property and homeowner information.
- 3
Check The Coverage Conditions
Review the form’s instructions for homeowners paying workers 40 or more aggregate hours per week.
- 4
Sign And Submit
Sign and date the form, then submit it to the city department named on the form.
Frequently asked questions
- What does the Homeowner Workers’ Compensation Exemption Form do?
- It lets eligible homeowners of one- to four-family owner-occupied residences state why specific proof of workers’ compensation coverage is not required for their building permit.
- Who can use this exemption form?
- The document describes homeowners listed as general contractor on a building permit for a qualifying owner-occupied residence who meet one of its listed conditions.
- Do I need a notary for the Homeowner Workers’ Compensation Exemption Form?
- No. This document is signed without a notary; the signer just signs and dates it.
- How do I submit the Homeowner Workers’ Compensation Exemption Form?
- Submit it to the city department named on the form; check the city website for current contact details.
Need something notarized?
This Homeowner Workers’ Compensation Exemption Form doesn’t need a notary — but if you have another Livingston form that does, a commissioned online notary can help.