Pittsburgh, PA · Allegheny County
Workers’ Compensation Exemption Affidavit
This affidavit states that no individuals will be employed for work under a Pittsburgh building permit, and applicants submit it to the Department of Permits, Licenses, and Inspections.
- 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
The Workers’ Compensation Exemption Affidavit states that no individuals will be employed to perform work under a building permit issued by Pittsburgh’s Department of Permits, Licenses, and Inspections (PLI). The applicant provides identifying and contact information, signs the affidavit, and has it affirmed and subscribed before a notary. PLI uses the form in lieu of proof of workers’ compensation insurance when the applicant makes the stated declaration.
Who needs it
A building permit applicant who will employ no individuals to perform the permitted work may submit this affidavit to Pittsburgh PLI in lieu of workers’ compensation insurance proof.
How to get this notarized
- 1
Download the Affidavit
Get Pittsburgh’s Workers’ Compensation Exemption Affidavit from the city form source.
- 2
Fill In Your Details
Enter the requested applicant, address, date, license, and phone information, and review the declaration.
- 3
Book an Online Notary
Schedule a remote session with a commissioned online notary.
- 4
- 5
Submit It to PLI
Send the completed affidavit to Pittsburgh’s Department of Permits, Licenses, and Inspections.
Preview the form
The blank PDF straight from Pittsburgh. 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 submits the Workers’ Compensation Exemption Affidavit?
- The applicant submits it to Pittsburgh’s Department of Permits, Licenses, and Inspections when stating that no individuals will be employed for work under the building permit.
- How do I complete the affidavit?
- Fill in the applicant and permit-related details, sign before a commissioned online notary, and submit the completed affidavit to PLI.
- Do I need to sign in front of a notary?
- Yes. The form includes an affirmed-and-subscribed jurat, and the applicant signs before the notary, who completes the jurat and applies a seal.
- Can I use an online notary for this form?
- Pennsylvania law authorizes remote online notarization under 57 Pa.C.S. §306.1; §311 gives an act performed in another state the same effect as one performed by an in-state notary. Confirm with the city, borough or township if unsure.
Workers’ Compensation Exemption Affidavit in other Allegheny County cities
Each city publishes its own version of this form. Pick the city where you’re filing.