Affidavit of Exemption to Show Specific Proof of Workers’ Compensation Insurance Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence **This form cannot be used to waive the workers’ compensation rights or obligations of any party.** Under penalty of perjury, I certify that I am the owner of the 1, 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): I am performing all the work for which the building permit was issued. I am not hiring, paying or compensating in any way, the individual(s) that is(are) performing all the work for which the building permit was issued or helping me perform such work. I have a homeowners insurance policy that is currently in effect and covers the property listed on the attached building permit AND am hiring or paying individuals a total of less than 40 hours per week (aggregate hours for all paid individuals on the jobsite) for which the building permit was issued. I also agree to either: ♦ acquire appropriate workers’ compensation coverage and provide appropriate proof of that coverage on forms approved by the Chair of the 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 jobsite) for work indicated on the building permit, or if appropriate, file a CE200 exemption form; OR ♦ 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 jobsite) for work indicated on the building permit. ___________________________________ (Signature of Homeowner) ___________________________________ (Homeowner’s Name Printed) ___________________ (Date Signed) Home Telephone Number ___________________ Property Address that requires the building permit: __________________________________ __________________________________ __________________________________ __________________________________ Once notarized, this BP-1 form serves as an exemption for both workers’ compensation and disability benefits insurance coverage. BP-1 (12/08) NY-WCB American LegalNet, Inc. www.FormsWorkflow.com LAWS OF NEW YORK, 1998 CHAPTER 439 The general municipal law is amended by adding a new section 125 to read as follows:  125. ISSUANCE OF BUILDING PERMITS. NO CITY, TOWN OR VILLAGE SHALL ISSUE A BUILDING PERMIT WITHOUT OBTAINING FROM THE PERMIT APPLICANT EITHER: 1. PROOF DULY SUBSCRIBED THAT WORKERS’ COMPENSATION INSURANCE AND DISABILITY BENEFITS COVERAGE ISSUED BY AN INSURANCE CARRIER IN A FORM SATISFACTORY TO THE CHAIR OF THE WORKERS’ COMPENSATION BOARD AS PROVIDED FOR IN SECTION FIFTY-SEVEN OF THE WORKERS’ COMPENSATION LAW IS EFFECTIVE; OR 2. AN AFFIDAVIT THAT SUCH PERMIT APPLICANT HAS NOT ENGAGED AN EMPLOYER OR ANY EMPLOYEES AS THOSE TERMS ARE DEFINED IN SECTION TWO OF THE WORKERS’ COMPENSATION LAW TO PERFORM WORK RELATING TO SUCH BUILDING PERMIT. Implementing Section 125 of the General Municipal Law 1. General Contractors -- Business Owners and Certain Homeowners For businesses and certain homeowners listed as the general contractors on building permits, proof that they are in compliance with Section 57 of the Workers’ Compensation Law (WCL) is ONE of the following forms that indicate that they are: ♦ insured (C-105.2 or U-26.3), ♦ self-insured (SI-12), or ♦ are exempt (CE-200), under the mandatory coverage provisions of the WCL. Any residence that is not a 1, 2, 3 or 4 Family, Owner-occupied Residence is considered a business (income or potential income property) and must prove compliance by filing one of the above forms. 2. Owner-occupied Residences For homeowners of a 1, 2, 3 or 4 Family, Owner-occupied Residence, proof of their exemption from the mandatory coverage provisions of the Workers’ Compensation Law when applying for a building permit is to file form BP-1. ♦ Form BP-1shall be filed if the homeowner of a 1, 2, 3 or 4 Family, Owner-occupied Residence is listed as the general contractor on the building permit, and the homeowner: ◊ ◊ is not hiring, paying or compensating in any way, the individual(s) that is(are) performing all the work for which the building permit was issued or helping the homeowner perform such work, or ◊ ♦ is performing all the work for which the building permit was issued him/herself, has a homeowner’s insurance policy that is currently in effect and covers the property for which the building permit was issued AND the homeowner is hiring or paying individuals a total of less than 40 hours per week (aggregate hours for all paid individuals on the jobsite) for the work for which the building permit was issued. If the homeowner of a 1, 2, 3 or 4 Family, Owner-occupied Residence is hiring or paying individuals a total of 40 hours or MORE in any week (aggregate hours for all paid individuals on the jobsite) for the work for which the building permit was issued, then the homeowner may not file the “Affidavit of Exemption” form, BP-1(11/04), but shall either: ◊ acquire appropriate workers’ compensation coverage and provide appropriate proof of that coverage on forms approved by the Chair of the NYS Workers’ Compensation Board to the government entity issuing the building permit (the C-105.2 or U-26.3 form), OR ◊ 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) 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. BP-1 (12/08) Reverse www.wcb.state.ny.us American LegalNet, Inc. www.FormsWorkflow.com