Fillable A. CONTACT INFORMATION (Please print or type answers. (Incorporated Village of Sag Harbor)

Fill Online, Printable, Fillable, Blank A. CONTACT INFORMATION (Please print or type answers. (Incorporated Village of Sag Harbor) Form

Use Fill to complete blank online INCORPORATED VILLAGE OF SAG HARBOR (NY) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

A. CONTACT INFORMATION (Please print or type answers. (Incorporated Village of Sag Harbor)

On average this form takes 40 minutes to complete

The A. CONTACT INFORMATION (Please print or type answers. (Incorporated Village of Sag Harbor) form is 7 pages long and contains:

  • 0 signatures
  • 61 check-boxes
  • 132 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Incorporated Village of Sag Harbor

BROWSE INCORPORATED VILLAGE OF SAG HARBOR (NY) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
INC. VILLAGE OF SAG HARBOR WETLANDS PERMIT APPLICATION
55 MAIN ST. • PO BOX 660 CHAPTER 285: WETLANDS
SAG HARBOR, NY 11963
(631) 725-0224
- 1 -
APPLICANT NAME:
_________________________________________
STREET ADDRESS OF PROPOSED PROJECT:
_________________________________________
SUFFOLK COUNTY TAX MAP NUMBER:
_________ – _________ – _________– _________
FOR OFFICIAL USE ONLY:
RECEIVED: __________________________
PERMIT FEE: _________________________
FEE PAID: ___________________________
PERMIT NO.: _________________________
DATE ISSUED: ______/______/______
A. CONTACT INFORMATION (Please print or type answers. Check off who should receive correspondence.)
Applicant: _______________________________________________________________________
Mailing Address: _________________________________________________________________
Telephone Number: ( ) ______________ Email Address: ___________________________
Applicant is the: ____ Owner ____ Lessee ____ Contract Vendee
Owner(s) (if not applicant): _________________________________________________________
Mailing Address: _________________________________________________________________
Telephone Number: ( ) ______________ Email Address: ___________________________
If applicant or owner is a corporation, give name, title & contact information for corporation offices.
Applicant Corporate Officer
Name: _____________________________________
Address: ___________________________________
Telephone Number: ( ) ___________________
Property Corporate Officer
Name: ____________________________________
Address: ___________________________________
Telephone Number: ( ) ___________________
Agent (if applicable): ______________________________________________________________
Mailing Address: _________________________________________________________________
Telephone Number: ( ) ______________ Email Address: ___________________________
Attorney (if applicable): ____________________________________________________________
Mailing Address: _________________________________________________________________
Telephone Number: ( ) ______________ Email Address: ___________________________
Anyone filing an application who is not the property owner must also submit an original copy
of the Owner’s Endorsement form (included with this application), signed & notarized by the
owner or authorized representative of the owner corporation.
Surveyor: _______________________________________________________________________
Mailing Address: _________________________________________________________________
Telephone Number: ( ) ______________ Email Address: ___________________________
License Number: _______________________
INCORPORATED VILLAGE OF SAG HARBOR WETLANDS PERMIT APPLICATION
Chapter 285: Wetlands Section B: Proposed Activities
- 2 -
B. PROPOSED ACTIVITIES
1) Review the list below and check all activities that are included in the proposed project.
New
Residential
Building
New
Commercial
Building
Addition:
Increase Size of
Footprint
Addition:
No Increase in
Footprint
Interior
Alteration
Renovate
Existing
Building
Reconstruct
Building
Swimming Pool. If checked, provide Cross Section for pool depth relative to groundwater elevation
Deck, Patio and/or Terrace. If checked, is the structure less than 12” above grade? Yes No
Fence: If checked, provide: Height (ft.) _______ Total Length (ft.) _______ Material ____________
Retaining Wall. If checked, is the retaining wall necessary for the septic system? Yes No
Other Accessory Building or Structure. If checked, list all proposed: ________________________
__________________________________________________________________________________
Demolition. If checked, specify what is being demolished & specify on site plan: _________________
__________________________________________________________________________________
New, Upgraded, or Expanded Private Septic System.
Placement of Fill. If checked, answer the questions below:
• Total Volume of Fill __________ cu. yds.
• Type & Purpose of Fill (Specify if fill will be used for septic & provide volume for septic fill): ________
________________________________________________________________________________
Excavation. If checked, specify: Maximum Depth (ft.) __________________________________
Avg. Existing Grade Elevation (NAVD 1988)_______________
Purpose of Excavation _________________________________
Dewatering. If checked, provide details of dewatering in separate written narrative.
Clearing of Vegetation. If checked, indicate limits of disturbance on site plan & provide area below:
• Area to be Cleared _____________ sq. ft.
• List Type(s) of Vegetation to be Cleared: ___________________________________________
Planting New Vegetation. If checked, provide a planting plan that shows types of proposed plants (with
common & scientific names), and the specific location, quantities, and sizes/spacing of those plants.
Dock. If checked, address §285-9(E)(3) and 285-9(F) in a separate written narrative.
Any work involving Erosion Control Structures (see definition under §285-3), including construction,
placement, installation, repair, reconstruction, replacement, or alteration. If checked, address §285-
9(E)(2) in separate written narrative.
Dredging. If checked, describe purpose in Question 3 below, or in a separate written narrative.
New Outdoor Lighting. If checked, address §285-9(G) in separate written narrative.
Other Activities Not Listed. If checked, describe other proposed activities in Question 3 below.
INCORPORATED VILLAGE OF SAG HARBOR WETLANDS PERMIT APPLICATION
Chapter 285: Wetlands Section B: Proposed Activities
- 3 -
2) What resource(s) may be affected by proposed activities? (Both may apply & should be indicated on
the submitted survey) Wetlands Bluff
3) Describe the proposed activities below or in a separate written narrative. (Be sure to include the
dimensions (area, length, or volume) of each proposed structure, and the setback of all proposed
activities to the wetland boundaries and property lines, if applicable.)
(If separate narrative is provided, please indicate below.)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
4) Do the proposed activities comply with the Wetland Setbacks (buffer zones) required under
§285-9(A) and/or the Bluff Setbacks required under §285-9(E)(1)? ______Yes ____ No
If the answer to this question is “No,” the applicant is required to demonstrate that no practicable
alternatives exist for the proposed project. Refer to §§285-9(D)(2) & (3) for more information
on how this needs to be addressed to fulfill minimum application requirements.
5) Lot Area: _______________ sq. ft.
6) Complete the table below based on existing and proposed conditions.
Areas should add up to Lot Area provided in Question 5.
Existing Areas
(sq. ft.)
Proposed Areas
(sq. ft.)
Proposed Change
(sq. ft. +/–)
7) Will the project exceed 300 gallons of water use per day? _____Yes _____No
• Approximate Water Use Per Day: ________________ gallons per day
INCORPORATED VILLAGE OF SAG HARBOR WETLANDS PERMIT APPLICATION
Chapter 285: Wetlands Section C: Zoning, Planning & Permitting Information
- 4 -
C. PROPERTY ZONING, PLANNING & PERMITTING INFORMATION
1) Zoning District: _____________
2) FEMA Flood Zone(s): _____________________________________
3) Suffolk County Groundwater Management Zone: ______________
4) Is the property in the Historic Overlay District? _____Yes _____No
5) Is the property in a Village Sewer District (see Village Code §220-1.3)? ____Yes _____No
6) Is the property connected to public water? ____Yes _____No _____N/A
7) Is the property part of a subdivision? _____Yes _____No
If Yes, provide the name of the subdivision and the lot number(s) of the property in that subdivision.
• Subdivision Name: _______________________________
• Lot Number(s): ______________
8) If there are any right-of-ways, easements, restrictive covenants, or other encumbrances on the
property, list what encumbrances exist and provide copies with your application.
If not, just write N/A
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
9) Have any wetlands permits ever been issued by the Village in the past? If so, provide the date
of the permit and the name of the person that the permit was issued to. If not, just write N/A
10) Check off whether approval is required any of the below agencies.
If possible, indicate the applicable Reference Number, Approval or Filing Date. If approvals have already
been secured, provide copies of the permit AND the stamped-approved plans.
Agency
Reference Number
Approval or Filing Date
NYS Dept. of Environmental Conservation
(including Letter of Non-Jurisdiction)
Suffolk County Dept. of Health Services
NYS Dept. of State
US Army Corps of Engineers
Southampton Town Trustees
Other (specify) ___________________________
________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
INCORPORATED VILLAGE OF SAG HARBOR WETLANDS PERMIT APPLICATION
Chapter 285: Wetlands Section D: Site Characteristics
D. SITE CHARACTERISTICS
1) Predominant Soil Type: _______________________________________________
2) Depth to Groundwater: _____________ ft.
• Groundwater depth should be based on recent on-site test hole data. Location of test hole must be shown
on survey. Test hole data will be required for certain types of projects including, but are not limited to,
swimming pools, new septic systems, houses with basements, and any excavation.
3) Approximately What Percentage of the Property is:
• Well Drained: __________ %
• Moderately Drained: __________ %
• Poorly Drained: __________ %
4) Does the property contain any species of plant or animal life listed as rare, threatened or
endangered by the New York State, the New York State Natural Heritage Program, to the
United States of America? _____ Yes _____ No
• If yes, please identify each species and its status as classified by New York State, the New York State
Natural Heritage Program, to the United States.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
STATE OF _________________________ }
} ss.:
COUNTY OF _______________________ }
________________________________________________ (applicant print name) being duly sworn, deposes and says that
he or she is the owner or authorized agent for of the property described in the foregoing application, and that all information
provided on this form and in all attachments submitted herewith are true to the best of his or her knowledge and belief.
The undersigned hereby hold harmless and indemnify the Incorporated Village of Sag Harbor, including its agencies,
officials and employees, against any claim, cost or expense, including attorney fees, by reason of their reliance upon this
authorization.
____________________________________
Signature of Applicant
Sworn to me this _____ day of_________________, 20____
____________________________________
Notary Public
INC. VILLAGE OF SAG HARBOR
55 MAIN ST. • PO BOX 660
SAG HARBOR, NY 11963
P: (631) 725-0222 • F: (631) 725-0316
OWNER’S ENDORSEMENT
To Be Signed If Applicant Is Not The Owner
If there are multiple owners, each owner must prepare an endorsement.
STATE OF ____________________ }
} ss.:
COUNTY OF __________________ }
_________________________________________, being duly sworn, deposes and says:
I am the (check one) [ Owner in fee | Officer of the Corporation which is the owner in fee ] of the
premises located at __________________________________ with the SCTM#: _____-_____-_____-_____
and described in the foregoing; and that I have authorized _________________________________________
to make the foregoing application as described herein.
The undersigned hereby hold harmless and indemnify the Incorporated Village of Sag Harbor, including its
agencies, officials and employees, against any claim, cost or expense, including attorney fees, by reason of
their reliance upon this authorization.
Signed: _____________________________________
Print Name: __________________________________
____________________________________________
If Corporation, name of Corporation
_____________________________________
Title of Corporation Officer that is Signing
Sworn to me this _____ day of_________________, 20____
____________________________________
Notary Public
INC. VILLAGE OF SAG HARBOR
55 MAIN ST. • PO BOX 660
SAG HARBOR, NY 11963
P: (631) 725-0222 • F: (631) 725-0316
AUTHORIZATION AND CONSENT FOR INSPECTION OF PROPERTY
By signing this permission form for submission with an application for a permit(s) to the
Incorporated Village of Sag Harbor, the signer consents to inspection by Village Board
Members, staff, and/or consultants of the project site or facility for which a permit is sought.
This consent allows Village Board Members, staff, and/or consultants to enter upon and pass
through such property in order to inspect the project site or facility without prior notice.
Inspections may take place as part of the application review prior to a decision to grant or
deny the permit(s) sought. By signing this consent form, the signer agrees that this consent
remains in effect as long as the application is pending, and is effective regardless of whether
the signer, applicant or an agent is present at the time of the inspection. In the event that the
project site or facility is posted with any form of "posted" or "keep out" notices, or fenced in
with an unlocked gate, this permission form authorizes Village Board Members, staff, and/or
consultants to disregard such notices or unlocked gates at the time of inspection.
The signer further agrees that during an inspection, Village Board Members, staff, and/or
consultants may, among other things, take measurements, may analyze physical
characteristics of the site including, but not limited to, soils and vegetation (taking samples
for analysis), and may make drawings and take photographs.
Failure to grant consent for an inspection is grounds for, and may result in, denial of the
permit(s) sought by the application.
Permission is granted for inspection of property located at the following address(es):
________________________________________________________________________________
________________________________________________________________________________
By signing this form, I affirm that I am authorized to give consent to entry by Village
Board Members, staff, and/or consultants as described above.
_____________________________________ ________________________ ______________
Print Name & Title Signature Date
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

A. CONTACT INFORMATION (Please print or type answers. (Incorporated Village of Sag Harbor)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 16 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document