Cheektowaga, NY · Erie County
Affidavit of Exemption for Workers’ Compensation Coverage
This affidavit lets eligible homeowners of one- to four-family owner-occupied residences document an exemption when applying for a building permit.
What this form is
The form is for a homeowner listed as the general contractor on a building permit for a one- to four-family owner-occupied residence, including a condominium. It asks the homeowner to select an eligible reason for exemption, then provide a signature, date, telephone number, printed name, and property address. The form explains that homeowners paying individuals 40 or more aggregate hours per week must provide coverage proof or have the general contractor do so.
Who needs it
A homeowner listed as the general contractor on a building permit may use this form if the residence and work meet one of its stated exemption conditions.
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 form has no notary block, and the signer signs and dates it; its text says the BP-1 serves as an exemption once notarized.
How to submit this form
- 1
Download The Form
Download the homeowner workers’ compensation exemption affidavit PDF.
- 2
Complete The Affidavit
Select the applicable exemption reason and enter the requested homeowner and property information.
- 3
Check The Coverage Conditions
Review the form’s instructions for homeowners paying individuals 40 or more aggregate hours per week.
- 4
Submit The Form
Submit it to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- Do I need a notary for the Workers’ Compensation Exemption Affidavit?
- No notary block appears on this form; the homeowner signs and dates it. The form text says the BP-1 serves as an exemption once notarized.
- Who can use the homeowner exemption affidavit?
- It is for a homeowner listed as the general contractor on a building permit for a one- to four-family owner-occupied residence, including a condominium, who meets a stated exemption condition.
- What information does the affidavit request?
- It asks the homeowner to select an exemption reason and provide a signature, date, home telephone number, printed name, and the property address requiring the building permit.
- How do I submit the homeowner exemption affidavit?
- Submit it to the city department named on the form; check the city website for current contact details.
Need something notarized?
This Affidavit of Exemption for Workers’ Compensation Coverage doesn’t need a notary — but if you have another Cheektowaga form that does, a commissioned online notary can help.