Revised 02/22/2017 Page 1 of 2
Building Department
All information must be complete to initiate the processing of the application
Please refer to Chapter 111, 136 and 280 of the Zoning Ordinance for additional requirements.
Violations of the Zoning Ordinance may result in the issuance of a Summons.
DATE: _______________
1) Property Information:
Street Address: _______________________________________________________________________ Section __________ Block __________ Lot ___________
2) Property Owner:
Name: _______________________________________________________________________________ Phone Number: ___________________________________
3) Contractor
Name: _______________________________________________________________________________ Phone Number: ___________________________________
License No:__________________________________________________
Description / Structure to be demolished: ___________________________________________________________________________________________________
All Tree removals associated with this application must be applied for at time of this permit application at the Department of Public Works.
I/We, _______________________________________________________ the Applicants herein, do hereby authorize the members of the Planning Board and the
Building Department to inspect our property as it relates to the foregoing Demolition application during reasonable hours and upon providing reasonable notice of said
inspection. I/We consent to the Planning Board and Building Department members to contact me/us at the phone number provided herein to arrange said inspection.
Property Owners signature: _______________________________ Date: ____________________
Contractors signature: ____________________________________ Date: ____________________
**Additional Conditions listed on the second page must also be complied with**
Six Foot (6-0”) chain link fencing is to be provided for around entire area of demolition and a lockable gate is to be
provided for access to and from site.
All debris, including footings and foundations, must be removed from the property.
Clean fill to be used for filling of any excavated portions of property. A Grading / Fill permit may have to be issued for this
Evidence that all utilities have been removed must be presented prior to issuance of demolition permit and certification from
Nassau County Department of Health that premise is free of rodents
Submittals: The following must be submitted with any application for demolition:
Utility Removals:
GAS Date of Letter: ____________
WATER Date of Letter: ____________
SEWER Date of Letter: ____________
ELECTRIC Date of Letter: ____________
RODENT CONTROL Date of Letter: ____________
ASBESTOS CERTIFICATE Date of Letter: ____________
Revised 02/22/2017 Page 2 of 2
Building Department
When are operations to begin? _________________________________________________________________________________
Details of Demolition:
Dwelling Garage Shed Barn Business Industrial Other
Size of Structure: _____________________________ Foundation: Yes No
Demolition of in-ground pools require a letter from an electrician stating electric has been disconnected
Appropriate mitigation methods shall be employed before, during and after the demolition to control the generation of
fugitive dust, storm water run-off and erosion.
Application Submittals:
Application must be filed out completely
If contractor is applicant, the contractor MUST provide consent from the homeowner authorizing him to file for
the Permit
Proof of Insurance The applicant shall file with the City of Glen Cove a Certificate of Insurance indicating
that the City has been named primary insured under an insurance policy in the amounts of ($300,000 / $500,000)
for bodily injury and ($50,000) for property.
Worker Compensation Proof of insurance must be submitted from the contractor and/or homeowner at the
time of submission.
The applicant hereby agrees to hold the City of Glen Cove harmless on account of damages of any kind which may arise
during the progress of the work authorized by this permit.
The applicant certifies all persons concerned with actual work under this permit are duly covered by Workman’s
Compensation Insurance and the City shall be harmless on account thereof.
Work under this permit shall commence within thirty (30) days of the date of this permit and shall be continued in an
expeditious manner.
The City shall have the right to select counsel to represent it for the defense of any claim, suit, or action arising hereunder,
all fees and disbursement for the same to be paid by the applicant herein.
The applicant shall be responsible for all damages caused to public utilities and shall replace any cracked or damaged sewer
or water mains with new pipe.
The applicant shall take every reasonable precaution to properly warn all persons of any danger during the course of the
The permit does not include any privileges of encroachment in, over, or under, or upon any city street or right-of-way.
In consideration of being granted this permit, the undersigned applicant accepts it subject to the conditions described.
I, __________________________________, the above-named applicant, hereby attest that I am
The lawful owner of the property described within or am the lawful Contractor/Agent of said Owner and affirm under the
penalty of perjury that all statements made by me on this application are true.
Signature: _________________________________________________ Date: _______________________