Northumberland, NY · Saratoga County
Workers' Compensation Exemption Affidavit
This affidavit lets an owner of a one- to four-family, owner-occupied residence explain why specific proof of workers' compensation coverage is not required for work under a building permit.
- licensed online notary
- ~15 min average
- Notarized PDF emailed
What you’ll need
- Government-issued photo ID
- Webcam-enabled device (laptop or phone)
- This form, ready to upload as a PDF
What this form is
Northumberland homeowners applying for a building permit for an owner-occupied residence can use this affidavit to state which exemption applies: doing the work themselves, not paying anyone to do it, or hiring workers for fewer than 40 aggregate hours per week while maintaining homeowners insurance. The owner also agrees to provide proof of coverage or a contractor's proof if the work reaches 40 or more aggregate hours per week. Submit it to the government entity issuing the building permit.
Who needs it
A homeowner applying for a building permit for an owner-occupied one- to four-family residence, including a condominium, who claims an exemption from showing specific workers' compensation proof needs this affidavit.
Why it needs a notary
The homeowner signs the affidavit under oath before a county clerk or notary public, who completes the form's “Sworn to before me” block.
How to get this notarized
- 1
Download the Affidavit
Get the Workers' Compensation Exemption Affidavit and the building permit materials for your project.
- 2
Complete the Form
Select the applicable exemption and fill in the homeowner and property details. Leave the oath section for the notary.
- 3
Book an Online Notary
Schedule a remote session with a commissioned online notary.
- 4
Sign on Video
Show identification and sign the affidavit during the online session before the notary completes the sworn statement.
- 5
Submit to the City
Send the notarized affidavit to the government entity issuing your building permit.
Preview the form
The blank PDF straight from Northumberland. Look it over, then upload your filled copy to start the notary session.
You’ll need ID and a webcam.
A licensed online notary will join you on video, verify your government-issued ID, witness your signature, and apply their seal. You’ll receive the notarized PDF by email when the session ends.
Frequently asked questions
- Who signs the workers' compensation exemption affidavit?
- The homeowner applying for the building permit signs the affidavit and prints their name. The form also asks for the property address and homeowner telephone number.
- How do I complete the affidavit?
- Check the box that describes your situation, complete the homeowner and property details, and sign before a county clerk or notary public. Submit the completed affidavit to the government entity issuing the building permit.
- Do I need a notary for this form?
- The form includes a “Sworn to before me” block for a county clerk or notary public, so the homeowner must sign before one of them.
- Can I sign this affidavit with an online notary?
- New York permits its notaries to perform notarizations online. Book a session with a commissioned online notary and sign during the video session.
- Which workers' compensation exemption should I select?
- The form lists three choices: you perform all the work, you do not hire or pay anyone to do the work, or you have homeowners insurance and pay workers for fewer than 40 aggregate hours per week. Confirm with the city, town or village if unsure.
Workers' Compensation Exemption Affidavit in other New York cities
Each city publishes its own version of this form. Pick the city where you’re filing.