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Home Owner Workman Compensation Form

  1. Under penalty of perjury, I certify that I am the owner of the I, 2, 3, or 4 family, owner-occupied residence (including condominiums) listed on the building permit that I am applying for, and I am not required to show specific proof of workers' compensation insurance coverage for such residence because:

    Please check the appropriate box.

  2. I also agree to either:

    -Option 1: Acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on forms approved by the Chair of the New York State (NYS) Workers' Compensation Board to the government entity issuing the building permit if I need to hire or pay individuals a total of 40 hours or more per week (aggregate hours for all paid individuals on the job site) for work indicated on the building permit.
    -Option 2: Have the general contractor, performing the work on the 1 , 2, 3 or 4 family, owner-occupied residence (including condominiums) listed on the building permit that I am applying for, provide appropriate proof of' workers' compensation coverage or proof of exemption from that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity. issuing the building permit if the project takes a total of 40 hours or more per week (aggregate hours for all paid individuals on the job site) for work indicated on the building permit.

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