INC. VILLAGE OF CEDARHURST
BUILDING PERMIT APPLICATION
200 Cedarhurst Ave. Cedarhurst, NY 11516
Office: (516)295-5770 Email: building@cedarhurst.gov Website: cedarhurst.
gov
Application No. Date rec’d. Permit No. Date issued
Number and Street Section Block Lot(s) Zone
N.S.E.W. side of __________________________________________________ feet N.S.E.W _____________________________________________
or N.S.E.W corner of ______________________________________________ & _____________________________________________________
TYPE OF IMPROVEMENT
New building or structure
Addition
Alteration
Use
Demolition
Foundation only
Other ______________________
___________________________
PROPOSED USE  For “Demolition” most recent use
Residential Nonresidental
Existing Proposed
One or Two Family
Mother Daughter/
Senior residence
Multi Family
Mixed Use
Other _______________
Existing (Specify) _______________
_____________________________
_____________________________
Proposed (Specify) ______________
_____________________________
WORK PROPOSED - Describe in detail: _________________________________________________________________
_______________________________________________________________________________________________
_________________________________________________________ COST OF IMPROVEMENT $ ________________
Pursuant to Worker’s Compensation Law,
an original certificate of insurance on form
C-105.21, C-105.2, U-26.3, SI-12, or GSI-
1 05.2 shall be filed with this department
prior to the issuance of any building permit.
PLEASE NOTE: Contractor is required
to obtain certificates or other proof of
Workers Compensation Insurance from all
subcontractors or any other person that is
not an employee of contractor and perform
or provide work, labor or services on the
site. Upon request by the village, contractors
must provide a copy of any such certificate
to the village. Failure to do so may result in
revocation of building permit(s)
CONSTRUCTION CLASSIFICATION
Existing Proposed
Type 1 - Fire resistive
Type 2A - Non-Combustible
Type 2B - Combustible
Type 3A - Ordinary Const.
Masonry wall
Type 3B - Wood Floor & Roof
Type 4 - Heavy Timber
Type 5 - Wood Frame
YES NO
Is a Sprinkler System Required?
Does The Building Have a
Sprinkler System?
STATUS OF WORK
Proposed
Under Construction
Completed
DIMENSIONS OF LOT
x
Total land area, square feet
Total square feet of floor area,
all floors, based on exterior
dimensions (exclus. base. or cellar)
Number of stories
Percent of lot occupied
%
Name Mailing Address - Number, Street, City, State and Zip Tel. No
Arch. or Engr.
Owner
Tenant
Contractor
Electrician
Plumber
Nassau County License Number
VILLAGE OF CEDARHURST License Number
VILLAGE OF CEDARHURST License Number
The owner of this building and the undersigned agree to conform to all applicable laws of the Village of Cedarhurst
AFFIDAVIT OF CONTRACTOR
AFFIDAVIT OF PROPERTY OWNER
STATE of NEW YORK
COUNTY OF NASSAU
(PRINT NAME) being duly sworn,
deposes and says: That he/she resides at
in the State of and that he/she is
authorized by the
Owner to make application for a permit to
perform said work in the foregoing application and accompanying plans, and all the
statement contained therein are true to deponent’s own knowledge.
Address
Phone
Sign Here
Sworn to before me this Day of 20
STATE of NEW YORK
COUNTY OF NASSAU
(PRINT NAME) being duly sworn,
deposes and says: That he/she resides at
in the of
in the State of ,that he/she is the owner in fact of all
that certain lot, piece or parcel of land shown on the diagram above situate, lying
and being within the INCORPORATED VILLAGE OF CEDARHURST, that the work
proposed to be done upon the said premises will be done in accordance with the,
approved application and accompanying plans, (and he/she hereby authorizes
APPLICANT
to make application for a permit to perform said work in the foregoing application
and accompanying plans) , and all the statements herein contained are true to
deponent’s own knowledge.
Sign here
Sworn to before me this Day of 20
(Applicant)
(Owner)
DO NOT WRITE BELOW THIS LINE - FOR DEPARTMENT USE ONLY
Adjusted Cost Permit Fee - 1st Permit Fee - 2nd Total Site Plan Fee
$
$
$
$
Approved by Permit Title
House No. Assigned
FEMA Flood
Hazard Zone
Zone By
Base Flood Elevation
Variance Yes No
If Yes date and case No.
Elevation Certificate: Yes No
Final Survey Required: Yes No
New C.O. Required: Yes No
Separate Application Required For:
HVAC Plumbing Electric
Sign/Awning Other
SCHOOL DIST SECTION BLOCK LOTS DATE
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