Bleecker, NY · Fulton County
Owner-Occupied Residence Coverage
This form lets owners of one- to four-family residences certify why they are not providing workers’ compensation proof with a building permit application.
What this form is
Owners of one- to four-family, owner-occupied residences, including condominiums, use this form to certify why they are not required to show proof of workers’ compensation coverage for work covered by a building permit. It asks the owner to select an applicable reason, agree to provide coverage or contractor proof if work reaches 40 or more aggregate paid hours per week, and provide signatures, contact details, and the property address.
Who needs it
An owner applying for a building permit for a one- to four-family, owner-occupied residence who is certifying an exemption from workers’ compensation proof needs this form.
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 and dated without a notary; it also asks for a witness signature, and identifies no notarized or sworn attachment.
How to submit this form
- 1
Download The Form
Download the Owner-Occupied Residence Coverage form.
- 2
Complete The Form
Select the applicable reason and provide the requested owner, contact, and property information.
- 3
Sign And Date
Sign and date the form, and obtain the requested witness signature.
- 4
Submit With Your Permit
Submit the form to the city department named on it with your building permit application.
Frequently asked questions
- Do I need a notary for the Owner-Occupied Residence Coverage form?
- No. The document has signature and date lines, plus a witness signature line, but no notary block or notarized attachment is identified.
- How do I submit the Owner-Occupied Residence Coverage form?
- Submit it to the city department named on the form; check the city website for current contact details.
- Who uses this coverage form?
- An owner applying for a building permit for a one- to four-family, owner-occupied residence, including a condominium, may use it to certify why workers’ compensation proof is not required.
- What information does the form request?
- It asks the owner to select an applicable reason, agree to provide coverage or contractor proof if work reaches 40 or more aggregate paid hours per week, and provide signatures, contact details, and the property address.
Need something notarized?
This Owner-Occupied Residence Coverage doesn’t need a notary — but if you have another Bleecker form that does, a commissioned online notary can help.