Chestnut Ridge, NY · Rockland County
Homeowner Waiver Affidavit
This affidavit lets eligible homeowners of one- to four-family owner-occupied residences explain why they are exempt from showing workers’ compensation coverage with a building permit.
What this form is
Homeowners listed as the general contractor on a building permit may use this affidavit to claim an exemption from showing workers’ compensation coverage for qualifying owner-occupied residences. It asks the homeowner to select the applicable exemption basis, certify the information under penalty of perjury, and provide a signature, date, contact number, name, and property address. The form describes different requirements when paid work totals 40 or more hours per week.
Who needs it
A homeowner listed as general contractor on a building permit for a one- to four-family owner-occupied residence may use this affidavit if an exemption condition applies.
How to submit it
Submit the affidavit to the government entity issuing the building permit. The document does not provide a specific department, address, email, portal, or fee.
About notarization
This document is signed and dated without a notary requirement; its text mentions notarization, but the form has no notary block and identifies no notarized attachment.
How to submit this form
- 1
Download The Affidavit
Download the Homeowner Waiver Affidavit PDF.
- 2
Review The Exemption Conditions
Check which listed exemption condition applies to your residence and the work covered by the building permit.
- 3
Complete And Sign
Select the applicable condition, provide the requested homeowner and property details, then sign and date the affidavit.
- 4
Submit With The Permit
Submit the affidavit to the government entity issuing the building permit.
Frequently asked questions
- What is the Homeowner Waiver Affidavit used for?
- Eligible homeowners listed as general contractor on a building permit use it to state why they are exempt from showing workers’ compensation coverage.
- Who can use this affidavit?
- It is for a homeowner of a one- to four-family owner-occupied residence listed as general contractor on the building permit, when one of the stated exemption conditions applies.
- Do I need a notary for the Homeowner Waiver Affidavit?
- No. This form has no notary block and does not require notarization; its text mentions notarization, but identifies no notarized attachment.
- How do I submit the Homeowner Waiver Affidavit?
- Submit it to the government entity issuing the building permit. The form does not give a specific department or contact details.
Need something notarized?
This Homeowner Waiver Affidavit doesn’t need a notary — but if you have another Chestnut Ridge form that does, a commissioned online notary can help.