Red Hook, NY · Dutchess County
Affidavit of Exemption to Show Special Proof of Workers’ Compensation Insurance
This affidavit lets an eligible owner of an owner-occupied one- to four-family residence explain why workers’ compensation proof is not required for a building permit application.
- 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 homeowner identifies the property and certifies that a stated exemption applies, such as doing all the work personally or not paying anyone to perform it. The form also addresses homeowners insurance and paid work hours, and requires the owner to agree to provide coverage proof or have the general contractor provide it if the project reaches 40 or more aggregate paid work hours per week. The Town of Red Hook Building & Zoning Department uses it with a building permit application.
Who needs it
An owner applying for a building permit for an owner-occupied one- to four-family residence, including a condominium, who claims an exemption from showing workers’ compensation insurance proof.
Why it needs a notary
The homeowner signs the affidavit under oath before the notary public named in the “Sworn to before me” block, who completes that jurat.
How to get this notarized
- 1
Download the Affidavit
Get the Affidavit of Exemption to Show Special Proof of Workers’ Compensation Insurance from the Town of Red Hook.
- 2
Complete the Form
Select the exemption that applies and fill in the homeowner, insurance, and property details.
- 3
Book an Online Notary
Arrange a remote notarization with a commissioned online notary before signing.
- 4
- 5
Submit to the Town
Send the completed affidavit with your building permit application to the Town of Red Hook Building & Zoning Department.
Preview the form
The blank PDF straight from Red Hook. 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 complete and submit this affidavit?
- Identify the property, select the exemption that applies, complete the homeowner and insurance details, and sign before a notary. Submit the completed affidavit with your building permit application to the Town of Red Hook Building & Zoning Department.
- Do I need to sign this form in front of a notary?
- Yes. The form says “Sworn to before me” and includes a County Clerk or Notary Public signature line, so the homeowner must take the oath and sign before the notary.
- Can I use a commissioned online notary?
- New York authorizes remote online notarization by a commissioned online notary under Executive Law §135-c, in effect since 2023. You can complete the oath and signing by video if the notary can notarize this form.
- Where do I submit the completed affidavit?
- The form identifies the Town of Red Hook Building & Zoning Department as the government entity issuing the permit. Confirm the submission process with the department; confirm with the city, town or village if unsure.
Affidavit of Exemption to Show Special Proof of Workers’ Compensation Insurance in other New York cities
Each city publishes its own version of this form. Pick the city where you’re filing.