Do I need a notary for the Workers’ Compensation Insurance Exemption Affidavit?

No. The document has no notary block; the owner signs and dates it and certifies the statement under penalty of perjury.

Who can use this affidavit?

An owner applying for a building permit for an owner-occupied one-, two-, three-, or four-family residence, including a condominium, can use it to claim an exemption from providing specific workers’ compensation proof.

What information does the affidavit ask for?

The owner selects the applicable exemption reason and provides a signature, date, printed name, and property address.

Oneonta, NY · Otsego County

No notary required

Workers’ Compensation Insurance Exemption Affidavit

This affidavit lets an owner of an owner-occupied one- to four-family residence explain why workers’ compensation insurance proof is not required for a building permit.

What this form is

Owners applying for a building permit for an owner-occupied one- to four-family residence, including a condominium, use this affidavit to certify an exemption from providing specific proof of workers’ compensation coverage. The owner checks the applicable reason, such as doing all the work personally, not paying anyone to help, or having homeowners insurance and paying workers fewer than 40 total hours per week. It also describes coverage or contractor-proof steps if work reaches 40 hours or more per week.

Who needs it

An owner applying for a building permit for an owner-occupied one- to four-family residence who claims an exemption from providing workers’ compensation insurance proof needs this affidavit.

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 owner certifies the statement under penalty of perjury and signs and dates the affidavit.

How to submit this form

1
Download The Affidavit
Download the Workers’ Compensation Insurance Exemption Affidavit.
2
Complete The Affidavit
Check the applicable exemption reason and provide the homeowner’s signature, date, printed name, and property address.
3
Gather The Building Permit
The affidavit refers to the building permit for the property; have that permit information available.
4
Submit The Affidavit
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 Insurance Exemption Affidavit?: No. The document has no notary block; the owner signs and dates it and certifies the statement under penalty of perjury.
Who can use this affidavit?: An owner applying for a building permit for an owner-occupied one-, two-, three-, or four-family residence, including a condominium, can use it to claim an exemption from providing specific workers’ compensation proof.
What information does the affidavit ask for?: The owner selects the applicable exemption reason and provides a signature, date, printed name, and property address.
How do I submit the affidavit?: Submit it to the city department named on the form; check the city website for current contact details.

Need something notarized?

This Workers’ Compensation Insurance Exemption Affidavit doesn’t need a notary — but if you have another Oneonta form that does, a commissioned online notary can help.