Who can use the Workers’ Compensation Exemption Affidavit?

Homeowners of one- to four-family, owner-occupied residences may use it when a listed exemption condition applies to work covered by a building permit.

How do I submit the Workers’ Compensation Exemption Affidavit?

Submit it to the government entity issuing the building permit. The form does not list an address, email, portal, or fee.

When can’t I use this exemption affidavit?

The form says not to use the affidavit if paid individuals work a total of 40 or more hours per week on the project; workers’ compensation coverage or proof of exemption is required instead.

Sea Cliff, NY · Nassau County

No notary required

Workers’ Compensation Exemption Affidavit for Owner-Occupied Residences

This affidavit lets homeowners of one- to four-family, owner-occupied residences explain why they are exempt from showing workers’ compensation coverage for building-permit work.

What this form is

Homeowners submit this affidavit with a building-permit application when they meet one of the form’s exemption conditions: doing all the work themselves, hiring no one, or paying workers for fewer than 40 total hours per week while covered by homeowners insurance. It asks for the homeowner’s certification, exemption reason, signature, date, telephone number, printed name, and property address. The form does not waive anyone’s workers’ compensation rights or obligations.

Who needs it

A homeowner applying for a building permit for an owner-occupied one- to four-family residence may use this affidavit if one of its listed exemption conditions applies.

How to submit it

Submit it to the government entity issuing the building permit; the form does not provide an address, email, portal, or fee.

About notarization

This form is signed and dated without a notary; it includes a certification under penalty of perjury, but no separate notarized attachment is specified.

How to submit this form

1
Download The Affidavit
Download the Workers’ Compensation Exemption Affidavit PDF.
2
Complete The Form
Check the applicable exemption reason and provide the requested homeowner and property information.
3
Sign And Date
The homeowner signs and dates the certification.
4
Submit With The Permit
Submit the affidavit to the government entity issuing the building permit.

Frequently asked questions

Who can use the Workers’ Compensation Exemption Affidavit?: Homeowners of one- to four-family, owner-occupied residences may use it when a listed exemption condition applies to work covered by a building permit.
Do I need a notary for the Workers’ Compensation Exemption Affidavit?: No. The form is signed and dated without a notary. It includes a certification under penalty of perjury, but no separate notarized attachment is specified.
How do I submit the Workers’ Compensation Exemption Affidavit?: Submit it to the government entity issuing the building permit. The form does not list an address, email, portal, or fee.
When can’t I use this exemption affidavit?: The form says not to use the affidavit if paid individuals work a total of 40 or more hours per week on the project; workers’ compensation coverage or proof of exemption is required instead.

Need something notarized?

This Workers’ Compensation Exemption Affidavit for Owner-Occupied Residences doesn’t need a notary — but if you have another Sea Cliff form that does, a commissioned online notary can help.