Fillable APPLICATION FOR CERTIFICATE OF APPROPRIATENESS (Incorporated Village of Sag Harbor)

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APPLICATION FOR CERTIFICATE OF APPROPRIATENESS (Incorporated Village of Sag Harbor)

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BROWSE INCORPORATED VILLAGE OF SAG HARBOR (NY) FORMS

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APPLICATION FOR CERTIFICATE OF APPROPRIATENESS
VILLAGE OF SAG HARBOR
55 MAIN ST., P.O. BOX 660
SAG HARBOR, NEW YORK 11963
PHONE: 631.725.0222
FAX: 631.725.0316
Date Received:_____________
Fee Paid: _____________
Property Location: ____________________________ Tax Map Number____- ____ - ____ -___
Legal Street Address and Number District Section Block Lot
Property Owner: ____________________________________________
Mailing Address: ____________________________________________
____________________________________________
Phone: ____________________________________________
Applicant: _________________________________________________
Mailing Address: ____________________________________________
____________________________________________
Phone: ____________________________________________
Applicant is: □ Owner □ Lessee □ Architect □ Builder □ Other:__________
_____________________________________________________________________________
_
If owner or applicant is a corporation or LLC, Furnish names of managing officers or members
Corporate/LLC Property Owner Name Corporate/LLC Applicant Name
Name: _________________________ Name:__________________________
Address: _______________________ Address: ________________________
_______________________ ________________________
INSTRUCTIONS
A building permit for exterior work shall not be issued until a Certificate of Appropriateness is
issued by the Board of Historical Preservation and Architectural Review (“BHPAR”). All
applications must include a written project description that provides an adequate amount of detail
to allow the BHPAR to make an informed decision. Applications which lack sufficient detail
concerning materials and design will be considered incomplete and returned to the Applicant.
Applications for a Certificate of Appropriateness for demolition or removal affecting a
landmark or contributing building within the Historic District or for buildings which
contain 3,000 square feet or more shall be subject to a mandatory public hearing.
Applications should include the following information, where applicable: Please type or print.
a. A site plan drawn to scale with dimensions, orientation, and location of buildings,
structures or landscape features and showing their relationship to buildings, structures or
landscape features of surrounding properties.
b. Plans, elevations, or diagrams drawn to scale of proposed alterations, additions, or new
construction and showing areas of existing building or property affected. All existing and
proposed materials and finishes should be identified on drawings and keyed to samples or
descriptions. Sections and details of doors, windows, etc. may be required.
c. Photographs covering the four sides of the property and additional coverage of the
affected area.
d. Written specifications, samples, or other description of existing proposed materials or
finishes. Manufactured objects should be identified by manufacturer, catalog number and
description.
e. For new construction a perspective drawing may be required showing the proposed
building or structure in context with surrounding properties.
f. A landscaping plan of the property may be requested.
g. If proposal includes a sign, provide a scale drawing of sign showing content of sign and
relationship to building or premises, type or method of illumination (if any), method of
attachment to building, samples of colors and all materials used, and type and style of
lettering.
PROJECT DESCRIPTION: (Provide a general description of the proposed work. Use additional
sheets if necessary.)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_________
Type of proposed work: Please check all that apply.
SITE WORK LANDSCAPE PLANTING
_______ Fence or Wall ________ Hedge along street boundary
_______ Driveway, walk, patio other pavement ________ Planting intended to screen
_______ Major excavation or regrading, berm ________ Other landscaping
_______ Swimming pool, Tennis court
_______ Other landscape element _______ BUILDING ALTERATIONS
________ Wall materials
BUILDINGS _________ Roof
_______ New Construction _________ Chimneys
_______ Addition _________ Foundation material
_______ Demolition _________ Doorways
_______ Removal (including storm/screen)
_________ Windows
SIGNS (including storm/screen)
_______ New sign __________ Porches and steps
_______ Alteration of existing sign __________ Trim
__________ Gutters and leaders
__________ Paint and stain
__________ Other _______________
LIST ALL EXHIBITS SUBMITTED WITH THIS APPLICATION:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____
CERTIFICATION
________________________________________________ states as follows:
(Applicant’s name)
1. I am interested in an application for a Certificate of Appropriateness now pending before
the Sag Harbor Board of Historic Preservation and Architectural Review.
2. I resided at ______________________________________________________________
3. The nature of my interest is the aforesaid application is as follows: __________________
_______________________________________________________________________
_
4. If applicant or owner is a corporation, list officers:
President: _______________________ Vice-President
___________________
Secretary: _______________________ Treasurer:
______________________
5. Do any of the following individuals have an interest as defined below, in the owner or
applicant:
A. Any New York State Officer, or
B. Any officer of employee of Sag Harbor.
For the purpose of this disclosure, an officer or employee shall be deemed to have an interest
in the owner or applicant when he, his spouse, or their brothers, sisters, parents, children,
grandchildren, or the spouse of any of them
a. is the applicant or owner, or
b. is an officer, director, partner, or employee of the applicant or owner, or
c. legally or beneficially owns or controls stock of a corporate applicant or owner, or
d. is a party to an agreement with such an applicant or owner, express or implied,
whereby he may receive any payment or other benefit, whether or not for services
rendered dependent or contingent upon the favorable approval of such application.
A person who knowingly and intentionally fails to make such disclosure shall be guilty of
misdemeanor as provided in General Municipal Law, Section 809.
______ Yes ______ NO
If “Yes”, state the resident and nature and extent of the interest of such individual.
_____________________________________________________________________________
_
(Name) (Residence)
_____________________________________________________________________________
_
(Extent of Interest)
AFFIDAVIT
STATE OF NEW YORK) ss:
COUNTY OF SUFFOLK
__________________________ being duly sworn, deposes and says: That (s)he (or applicant’s
agent) resides at _______________________________________________________ and is the
Owner (or agent for the owner) of the premises described and that the applicant (or agent for the
Applicant) herein has been authorized to make this application: that (s)he has read the above
application and reviewed the attached photographs, drawings, samples and descriptions and that
to the best of his/her knowledge and belief said information is a true and correct representation of
the work proposed.
Sworn to before me this ______________ day of _________________ 20 __________________
__________________________________ _____________________________________
NOTARY PUBLIC APPLICANT OR AGENT FOR APPLICANT
_____________________________________________________________________________
_
FOR OFFICE USE ONLY
The Board of Historic Preservation and Architectural Review met on __________ and following
the review of this application as submitted did (approve, disapproved, approve with conditions
indicated below) that the project as specified ( is , is not) congruous with the Village of Sag
Harbor’s Historic Preservation Ordinance Article XIII of Chapter 300.
Conditions: ___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
______
_________________________ Signed Chair or Vice Chair _____________ Date ____________
Dated: 9/12/16
THIS FORM MUST BE PRINTED ON LEGAL SIZE PAPER
APPLICATIONS PRINTED ON LETTER SIZE WILL BE REFUSED
Kathleen Mulcahy, Mayor
James L. Larocca, Trustee
Aidan Corish, Trustee
Beth M. Kamper, Clerk-Administrator
BUILDING DEPARTMENT
55 Main St., PO Box 660
Sag Harbor, N.Y. 11963-0015
Tel: 631-725-0224 Fax: 631-725-4852
Thomas C. Gardella, Deputy Mayor
Robert Plumb, Trustee
Denise R. Schoen, Village Attorney
Rhonda L. Meserole, Village Treasurer
OWNER’S AUTHORIZATION
The undersigned are the sole owners of the premises located at:
________________________________________, Sag Harbor, New York.
SCTM: # _________________________________________ and hereby authorize
________________________________________________ to apply for and obtain:
Check as applicable:
(a) Building Permit ( )
(b) Certificate of Occupancy ( )
(c) Zoning Variance ( )
(d) Subdivision Approval ( )
(e) Certificate of Appropriateness
(f) Other ___________________________ (Describe)
The undersigned hereby hold harmless and indemnify the Village of Sag Harbor,
including its agencies, officials and employees, against any claim, cost or expense,
including attorney’s fees, by reason of their reliance upon this authorization.
Dated: __________________ Sign Here: _____________________________________
Print Name:_____________________________________
Sign Here: _____________________________________
Print Name:_____________________________________
On the _______ day of _______________, 20__ before me, the undersigned personally
appeared__________________________________________________, personally
known to me or proved to me on the basis of satisfaction evidence to be the individual(s)
whose name(s) is/are subscribed to within instrument and acknowledged to me that
he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their
signature(s) on this instrument, the individual(s) acted, executed the instrument.
__________________________________ Signature of Notary
Kathleen Mulcahy, Mayor
James L. Larocca, Trustee
Aidan Corish, Trustee
Beth M. Kamper, Clerk-Administrator
55 Main St., PO Box 660
Sag Harbor, N.Y. 11963
631-725-0222
631-725-0316 FAX
Thomas C Gardella, Deputy Mayor
Robert Plumb, Trustee
Denise R. Schoen, Village Attorney
Rhonda L. Meserole, Village Treasurer
Disclosure Affidavit
General Municipal Law §809
STATE OF NEW YORK}
} ss.:
COUNTY OF SUFFOLK}
____________________________________, being duly sworn, deposes and
says that:
1. (a) an application has been made by _______________________________
Name of applicant
to the __________________________________________________________, of the
Name of Village Agency
Village of Sag Harbor with respect to property situate at _______________________,
Street address
Sag Harbor, New York. I am the ________________________________________,
Applicant or Agent for applicant
I reside at _______________________________________.
Address of applicant or agent
(b) The shareholders, partners or members of the applicant corporation,
partnership or limited company are (if applicable):
(1) _______________ (3) _________________
(2) _______________ (4) _________________
2. (a) the landowner’s name and address are:
______________________________________________
______________________________________________
(b) The shareholders, partners or members of the landowner corporation,
partnership or limited company are (if applicable)
(1) _____________________ (3) ______________________
(2) _____________________ (4) ______________________
3. (a) the contract vendee’s name and address are (if applicable):
____________________________________________________
____________________________________________________
(b) The shareholders, partners or members of the contract vendee
corporation, partnership or limited company are (if applicable):
(1) ___________________ (3) ________________________
(2) ___________________ (4) ________________________
4. Does any officer or employee of the Village of Sag Harbor have an interest in
the applicant or in the landowner or in the contract vendee?
_______ Yes ______ No
If yes, state the name and residence of such officer or employee and the nature
and extent of such interest.
________________________________________________________
________________________________________________________
For the purpose of this disclosure, an officer or employee of the Village of
Sag Harbor shall be deemed to have an interest in the applicant or in the landowner or in
the contact vendee when he, his spouse, or their brothers, sisters, parents, children,
grandchildren, or the spouse of any of them:
(a) is the applicant or landowner or contract vendee, or
(b) is an officer, director, partner, member or employee of the applicant or
landowner or contract vendee, or
(c) legally or beneficially owns or controls stock of a corporate applicant or
landowner or contract vendee, or is a partner or member of a partnership or limited
liability company applicant or landowner or contract vendee; or
(d) is a party to an agreement with such an applicant or landowner or
contract vendee, express or implied, whereby he may receive any payment or other
benefit, whether or not for services rendered, dependent or contingent upon the favorable
approval of such application.
A person who knowingly and intentionally fails to make such disclosure shall be guilty of
a misdemeanor as provided in General Municipal Law §809.
________________________________________________________________________
________________________________________________________________________
5. Does any officer or employee of the Town of Southampton and/or East Hampton,
County of Suffolk or State of New York have an interest in the applicant or in the
landowner or in the contract vendee?
_________ Yes ___________No
If yes, state the name and residence of such officer or employee, the name of
such governmental entity (Town, County, and State) and the nature and extent of such
interest. ____________________________________________________________
For the purpose of this disclosure, an officer or employee of the Town of Southampton
and/or East Hampton shall be deemed to have an interest in the applicant or in the
landowner or in the contact vendee when he, his spouse, or their brothers, sisters, parents,
children, grandchildren, or the spouse of any of them:
(a) is the applicant or landowner or contract vendee; or
(b) is an officer, director, partner, member or employee of the applicant or
landowner or contract vendee; or
(c) legally or beneficially owns or controls stock of a corporate partnership or
limited liability company applicant or landowner or contract vendee; or
(d) Is a party to an agreement with such an applicant or landowner or contract
vendee expresses or implied, whereby he may receive any contingent upon the favorable
approval of such application.
A person who knowingly and intentionally fails to make such disclosure shall be guilty of
a misdemeanor as provided in General Municipal Law §809
___________________________________
Applicants Signature
State of New York)
) ss:
County of _____________)
On the ______ day of ___________in the year__________ before me, the undersigned,
personally appeared _______________________, personally known to me or proved to
me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are)
subscribed to the within instrument and acknowledged to me that he/she/they executed
the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the
instrument, the individual(s), or the person upon behalf of which the individual(s) acted,
executed the instrument.
______________________________________
(Notary Public)
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APPLICATION FOR CERTIFICATE OF APPROPRIATENESS (Incorporated Village of Sag Harbor)

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Completed 16 July 2020

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