BUILDING
DEPARTMENT
Inc. Village of Sag Harbor
55 Main St., P.O. Box 660
Sag Harbor, N.Y. 11963
631-725-0224
631-725-4852 FAX
buildingdept@sagharborNY.gov
APPLICATION FOR DEMOLITION PERMIT
TAX MAP NUMBER: ______ - ______ - ______ - ______ PROPERTY LOCATION: ___________________________
DISTRICT SECTION BLOCK LOT LEGAL STREET ADDRESS AND NUMBER
PROPERTY OWNER:___________________________ APPLICANT:______________________________
MAILING ADDRESS:___________________________ MAILING ADDRESS:______________________________
___________________________ ______________________________
PHONE:___________________________ PHONE:______________________________
APPLICANT IS: OWNER LESSEE AGENT ARCHITECT BUILDER OTHER:__________________________
IF OWNER OR APPLICANT IS A CORPORATION, FURNISH NAMES OF MANAGING OFFICERS OR PARTNERS:
CORPORATE PROPERTY OWNER CORPORATE APPLICANT
NAME: ____________________________________ NAME: ____________________________________
ADDRESS: ____________________________________ ADDRESS: ____________________________________
____________________________________ ____________________________________
PHONE: ____________________________________ PHONE: ____________________________________
CONTRACTOR RESPONSIBLE FOR CONSTRUCTION:
NAME: _____________________________________
PHONE: _____________________________________ CONTRACTORS LICENSE NO:___________________________
WORKERS COMPENSATION NO.:________________ ISSUED BY: SOUTHAMPTON EAST HAMPTON SUFFOLK
START DATE:______________________ COMPLETION DATE: ______________________
Workers’ compensation certificate must be attached to this application.
A recent title certification indicating lienholders (or lack thereof) must be attached to this application.
NOTE: The building department does not determine suitability of documentation regarding liens. Please refer to 300-17.2(A):
“No permit authorizing the demolition of a building shall occur unless the applicant provides a current title report approved as to form by the Village
Attorney, enabling identification of any mortgagee or lienholder encumbering the premises, and the applicant further provides a written executed
consent from any said mortgagee and/or lienholder authorizing said demolition, with any said consent in a form and substance approved by the
Village Attorney.”
ARE THERE ANY LIENS ON THE PROPERTY TO BE DEMOLISHED? Yes No
DESCRIPTION OF BUILDINGS AND STRUSTURES TO BE REMOVED; DESCRIBE EXISTING USE OF EVERY STRUCTURE:
STA
TE OF NEW YORK } ss.:
COUNTY OF __________________ }
_____________________________________ being duly sworn deposes and says that he is the applicant above named, he is the
NAME OF INDIVIDUAL SIGNING APPLICATION
______________________________, and is duly authorized to perform or have performed the work described above and to make
CONTRACTOR, AGENT, OWNER, ETC
.
and file this application; that all statements contained in this application are true to the best of his knowledge and belief; that the
work
will be performed in the manner set forth in the application; and that the work shall comply with all applicable laws, ordinances
and regulations.
Sworn
to before me this
_____
______ day of ______________________ 20____ ______________________________________
SIGNATURE OF APPLICANT
______
_______________________________
NOTARY PUBLIC
Notary Public _____________ County
REC
EIVED:________________
PERM
IT NO.:______________
LIENS VERIFIED: Yes
FEE: $___________________
HISTORIC PRESERVATION AND ARCHITECTURAL REVIEW BOARD
DATE:_________________
click to sign
signature
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