Saltaire, NY · Suffolk County
Workers’ Compensation Exemption Affidavit
Homeowners applying for a building permit use this affidavit to certify why they are exempt from providing specific proof of workers’ compensation coverage.
What this form is
This affidavit is for owners of one- to four-family, owner-occupied residences who are applying for a building permit and claim they do not need to provide specific proof of workers’ compensation insurance coverage. It asks the homeowner to select the applicable exemption, certify the details under penalty of perjury, and provide a signature, date, telephone number, printed name, and property address. The form also describes coverage or proof requirements if paid work reaches 40 hours or more per week.
Who needs it
A homeowner applying for a building permit for an owner-occupied residence with one to four families may use this affidavit if claiming an exemption.
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; it requires the homeowner’s signature and date, and the certification is made under penalty of perjury.
How to submit this form
- 1
Download The Affidavit
Download the Workers’ Compensation Exemption Affidavit PDF.
- 2
Complete The Form
Select the applicable exemption and enter the requested homeowner and property details.
- 3
Sign And Date
The homeowner signs and dates the certification under penalty of perjury.
- 4
Submit To The City
Submit the affidavit to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- Who can use the Workers’ Compensation Exemption Affidavit?
- It is for an owner of a one- to four-family, owner-occupied residence who is applying for a building permit and claims an exemption from providing specific proof of workers’ compensation coverage.
- What information does the affidavit ask for?
- The homeowner selects the applicable exemption and provides a signature, date, home telephone number, printed name, and the property address requiring the building permit.
- Do I need a notary for the Workers’ Compensation Exemption Affidavit?
- No. The form has no notary block; the homeowner signs and dates it, making the certification under penalty of perjury.
- How do I submit the Workers’ Compensation Exemption 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 Exemption Affidavit doesn’t need a notary — but if you have another Saltaire form that does, a commissioned online notary can help.