Fillable Building Permit Building Permit (Inc. Village of Freeport)

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Building Permit Building Permit (Inc. Village of Freeport)

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BROWSE INC. VILLAGE OF FREEPORT (NY) FORMS

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DIRECTIONS
FOR
FILLING
OUT
BUILDING
PERMITS
Papers
needed
to f!le
are:
Photocopy
of
current
Nassau
County
contractor
's license,
Workers
'
Compensation
General
Liability & Disability insurances.
Signed
Contract
between
contractor
and
business/homeowner
Building
Permit
Application
Nassau
County
Assessors
Sheet
2 copies
of
the
current
property
survey
2 copies
of
plans
and
drawings
Environmental
Review
Form
(white)
Water
letter
(if
applicable; i.e., pools,
new
plumbing)
1
copy
of
Electrical
Dept.
letter
**
2 copies ofN.Y.S.
Energy
calculations
Applicatioa fee is
based
on
cost
of
construction:
DOUBLE
FEE
WILL
BE
ASSESSED
IF
WORK
BAS
STARTED
NOTE:
All additions,
alterations
and
new
constructioa
must
meet Village
Ordinance
requirements.
*Applications
will
be
accepted
from
8;30 A.M.
to
3:00 P.M
.•
DaiJv.
They
must
be
submitted
in
person.
~
mail aopljcations will
be
accepted. No
work
may commence until c
ontractor
's information
or
homeowner's
iosuruce
is provided.
The
Building
Permit
Application fee
must
be
submitted
at
time
of
filing.
Plan
requirements
vary
,
but
generally all construction
work
requires
black
or
blue
oa
white
SCALE
drawings,
including floor plans,
framing
details
and
elevations.
Further
details
may
be
required
depending
on
job
complexity.
IF
ORA WINGS
SUBMITIED
WERE
PONE
ON A COMPUTER,
AN
ELECTRONIC
COPY
(DISC
OR
CD) MUST ALSO BE EMAILED
TO;
buildingdept@freeportny.gov
1.
PRINT
OR
TYPE
all
information
required
.
2.
COMPLETE
ALL
areas
required
for
the
work
you
will
be
performing.
3.
ALL
Sections I
through
IV
are
required
for
all
applications.
SECTION
I
Zoning
District will
be
iilled
in
by
this office. Section, Block &
Lot
may
be
obtained
from
a Deed
or
Tax
Bill,
but
must
be
verified
and
stamped
by
the
Village Assessor's Office.
Lot
size is obtained
from
the
property
survey
and
lot
area
is computed
from
that.
SECTIONil
Parts
A & B:
Check
off the bo:x/boxes
that
apply
to
your
new
and/or
existing buildings.
Part
C :
List
the
total
cost.
Total
includes: a &
d,
which
must
be
listed separately,
where
applicable.
Part
D:
Include
in
this section
the
overall sizes
of
the
structure,
i.e., one-story,
9'
x
12'2"
extension
for
den.
SECTION
Ill
1.
If
the
work
to
be
done
is
contracted
by
a lessee (tenant),
written
permission
must
be
submitted
from
the
property
owner.
2.
The
contractor's
name
and
full
address
must
be
supplied.
3.
All
work
that
is
deemed
structural
will
require
to
be
designed,
drawa
and
stamped
by
a New
York
State
licensed
architect
or
engineer.
SECTION
IV
Complete affidavit
portion
and
have
the
signature
notarized.
Copy
of
workmen's
compensation
sheet
naming
Village
of
Freeport
as a
named
insured. Also a copy
of
license
from
Nassau
County
Dept.
of
Consumers
Affairs. No
work
may
commence until copies
of
contractor
's
information
or
homeowoer's
insurance
is
provided.
SECTIONV
This
information
is
required
to
insure
flood
protection
and
show
that
the
minimum
area
requirements
are
met.
1.
Elevations
are
listed on the
property
survey.
2.
The
contractor's
name
and
full
address
must
be
supplied.
3.
Percentage
of
lot
coverage is
computed
from
building
area
and
lot
square
footage.
* A
drawing
is
required
showing
the
present
buildings, accessory structures, etc.,
and
the
location
of
new
work
in
relation
to
same.
You
may
copy
your
property
survey
and
locate
new
work
on
that.
Provide
two (2)
additional
copies
if
you
choose
this
method.
**
For
new
projeds
only -
not
required
for
small extensions.
POOLS
-
Submit:
a)
Complete Building
Permit
Application.
b)
Two
(2) copies
of
property
survey, locate
on
survey
where
fence & pool is going/or is.
c)
Water
availability letter.
FENCES
-
a)
Complete Building
Permit
Application.
b)
Two
(2) copies
of
property
survey, locate
on
survey
where
fence is going/
or
is.
c)
List
height
of
fence,
type
of
fence, bow
many
feet
of
fence
is
being installed,
and
if
it
is a new fence
or
a
replacement
and
if
it
is a solid
or
open
fence.
ALL
APPLICATIONS
MAY
BE
SUBJECT
TO
SITE
PLAN
REVIEW
AND/
OR
ZONING
BOARD
APPROVAL.
IF
SUBJECT
TO
ANY
OF
TUE
ABOVE,
IT
MAY
EXTEND
THE
TIME
FRAME
THAT
THE
BUILDING
DEPARTMENT
CAN
ISSUE
YOU
YOUR
PERMIT.
FOR
ANY
ADDITIONAL
INFORMATION,
CONTACT
THE
BUILDING
DEPARTMENT
@
377-2241.
I '
..
DEPARTMENT
OF
BUILDINGS
OF
THE
VILLAGE
OF
FREEPORT
..
N.Y.
APPLICATION
NO.
__
_
FHlnt
Date.
______
_
Application
for
Erection
of
Buildings
or
Alterations
IMPORTANT
- Applicant
to
complete all items in sections:
I,
II,
HI,
IV,
V
ZONING
I.
AT
ILOCATION)
DISTRICT
LOCATION
(flto.)
CStr-)
OF
BETWEEN
AND
BUILDING
lCroM
Str-)
ccr-str-1
APPAO><.
L.OT
Sl!CTION
DLOCK
LOT
LOT
SIZE
)(
AREA
II.
TYPE
AND
COST
OF
BUILDING
- All applicants complete Parts
A.
o.
A.
TYPE
OF
IMPROVEMINT
8.
PROPOSED OR EXISTING
USE
1 I
I
New
building
1
Addnion•Alt.,etlon
Clf
rnktentlel,
RESIDENl
IAL
NON
RESIDENTIAL
•
Corn.,lete
Pen
''E"
2 I
11
'
I
One
f'emily
17
I I
lndUatrlel
.,.,.,
fturnh<W
of
- hoU91ng
unlla
added.
If
non-tete
ftOne
12
I
I
Two
femll._
1a
I
I
Office.
benk,
prof-loft81
------
3 I
I
Swi1nmlno
Pool
13
I
I
APettment
·Enter
No.
of
Unlta
__
19
I
I
Stor•,rnercantlle
4
I
I
Aepei•
lreplecernentl
14
I
I
Trenalent
hotel,
rnotell,
or
20
I
I
Church,
other
r
..
lglo111
5
I
I Bulto.tieed
IN-.
Aepell)
dOrmitory
•
Enter
No.
of
Unlra
__
21
I
t
Hoapit•I,
IMtltutlonel
& I
I
Fence
1&
I
I
Ger
...
or
Acc:-•y
Structure
22
I
I
Other
• SSMClfy
1&
I
I
Other
•
S-lfy
1 I
I Moving
lr!llOQtlon)
-----·-----
-·---
------------
C.COST
D.
DESCRIPTION
OF
PROJECT
10
TOTAL
COST
OF
IMPROVEMENT
s
Ill.
IDENTIFICATION
- To
be
completed
by
ell applicants
NAME
MAILING
ADDRESS
-
Number.
air..-,
city
end
etete,
Zip
TEL..NO.
'·
Owner
or
L-
2.
Contrec:tor
3.
Arc:hllec:t
or
Engl-
.
IV.
OWIER
•
CONTRAmR
lrATEMllT
v.
FLOOD
ZDNE
Bulldl"ll
P"mlt
I• laued IUbJect
to
die
prO'lillanl
of
Slalon
17
ol
ttui
Workmmt'•
~
Law.
IS
PROJEQT
LOCATED
WITHIN
Work"*''•
Comsllnutlon
Cwtlflcne
liio.
Compeny Exp.Date
A
DESIGNATED
FLOOD
HAZARD
ZONE?
Contrector
YES
NQ.
or
Owner
IF
YES,
WHICH
ZONE'?,
__
lftrlnt)
Adclr"'
IS
PROJECT
TO
REPAIR
Phone
FLOOD
DAMAGE?
YES
NO
Stat•
of
NIW
York
Counw
of
N-
PROJECT DESCRIPTION
Mint
cluly
-•n,
...,.
tlllt
la
the
wntrector
or
Total/First Fir I
I
!Print) CHtorShel
own1r
of
lhe
~·
mentioned building.
That
the
lttml
of
the
lllow
eppllcetion
lllo
the
lltl11111ted
GOit
of
llld
build!,.
or
II·
Square Feet
i.ratlon,
It
corrKt
to
Iha beat
of
I:_..,..
end
Oellsf
and..,_
to
conform
to
all
lppllCllllll
lmws
of
thlt
Upper Firs
I
I
(Hl1orHerl
Square Feet
jurl.,lctlon.
S-n
to
btfD,.
me
thla
day
#
of
Fixtures
I
I
of
,20-
#of
Floors
I
I
I I
NDtll\I
Pulltlc,
CAlllllllMt
........
Occup.
iype
County,
N.Y.
Vt.
VALtDATtH
(Otlillll
U.
Olly)
lulldilll
""""
NurnlMr
Applowdby:
lulldlng
Pemlltl....i
lulldl111
Plmlit
FM8
~of
lulldlftll
.
,.,...
BUILDING PERMIT
RESIDENTIAL PROPERTY
DEPARTMENT
OF
ASSESSMENT
NASSAU
COUNTY
240 Old
Country
Road, Mineola, NY 11501
NBHD# (ASSESSOR
USE
ONLY)
~
t:D~A-=T=-E~R-=E~c=·D~(A~S~S~E~S~S"!!!O'!!!R~U~S~E~O!'!'N'!'!"L~Y)---1
z
1------~------------..,..;.T~OW,;.;.;.;N~·~C~ITY;.;..·~V~IL~LA;;.;,;;;;G~E~O~F~:;;;;;;;;;;;;;;;;;;;;p;;;;;;;;;;;;;;;;;;;;::;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;
;;;;....
__
.+,
________________________
__.
0
SECTION
BLOCK LOT
(S)
SCH
DIST# PERMIT#
SPECIFIC
ZONING
DESIGNATION
(')
t-------t--------------t----------------+------t------------------t--------------------------1%
0
0
t-----""t::'~~:"::'="'~~~~~------------------
.....
~~":":::~----------~------------------------"'"'r
Location of
N.E.S
.W.
SIDE
OF
{OR
CORNER
OF}
N.E.S.
W.
SIDE
OF
0
b.::B=ul~ld=mg~=====-------------
------------------+---------~~~~~-------------------------t
~
ADDRESS
OF
PROPERTY
NAME
OF
BUSINESS
-
0
Check one
t=:~~-=-~=---------------------------==-----t---------t:~=-=~==-:-:=-:-:=~---------------------1~
CITY,
TOWN,
VILLAGE
ZIP
CONTACT
PERSON/OWNER
..,_
___________________
___________
_,. D OWNER
ESTIMATED COST OF CONSTRUCTION:
OR
ADDRESS
0 LESSEE
CITY,
STATE,
ZIP
"'
WORK MUST BEGIN BY
~~,,--------------------------------t
m
PRINCIPLE
TYPE
OF
(')
·
..
CONSTRUCTION
__________________________________ _.
:::!
0
z
PERMIT EXP DATE
D
STEEL
LOT SIZE S.F.
D
MASONRY
# BLDGS
ON
LOT
D
FRAME
DETAILED
DESCRIPT.ION
OF
WORK (PLEASE PRINT CLEARLY)
IF YOU WISH TO GROUP OR APPORTION LOTS
PLEASE
CALL
516-571 -1500 FOR FURTHER INFORMATION
m
*INCLUDING, BUT NOT LIMITED TO: LOCATION,
TYPE
AND DIMENSIONS
OF
IMPROVEMENT r
i-----------------------------------------------------------------------------
....
0
PERMIT
TYPE·
CHECK
ALL
ITEMS THAT APPLY
0 NEW BUILDING
0ADDITION
(CHANGE
IN
S.F.)
0 DEMOLITION
OALTERATION
(NO
CHANGE
IN
S.
F.)
0 MAINTAIN (PRE-EXISTING)
0 RECONSTRUCTION-
0 DECK, TERRACE, PORCH, CARPORT
0DORMERS
OOTHER
___________
__
0 FIRE DAMAGE
0 GARAGE/ OUT BUILDING
OHVAC
0PLUMBING
0 RELOCATION
0 REPLACEMENT
0 SWIMMING POOL
0TENNIS
COURT
0 CHANGE
IN
USE
PROPOSED TOTAL PLUMBING FIXTURES
DOES RESIDENCE HAVE
THE FOLLOWING
FINISHEDATIIC YES 0
NO
0
BASEMENT FINISH
1/4 D 1/2 D 3/4 D
FULL
D
(')
"
FLOOR/FIXTURE
BASEMENT 1ST FLOOR
2NDFLOOR
3RD FLOOR
BATHROOM SINK
1----------------------------------------------------------------------------------------~
~
TOILET
'"
-----------------------------------------------------------------------------------------~-
BATHTUB 0
,__
__________________________________________________
--+----------------------------------~::u
STALL SHOWER
-----------------------------------------------------+----------------------------------~m
BIDET r
----------------------------------------------------------------------------------------~o
KITCHEN SINK
(i)
---------------------+---------------+-----------------1------------------+-----------------~~
WET BAR
NUMBER OF EXISTING AND PROPOSED BATHS
NUMBER
OF
EXISTING FULL BATHS NUMBER
OF
PROPOSED FULL BATHS
NUMBER
OF
EXISTING HALF BATHS NUMBER
OF
PROPOSED HALF BATHS
HALF
BATH
EQUALS TWO FIXTURES, FULL BATH EQUALS THREE OR MORE FIXTURES
C:
-------------------------
----------------------~
o
~----~
o
~------------------------------11~
NEW C/O NEEDED YES
NO
-,
VARIANCE OBTAINED
YES
0
NO
0
~
CONSTRUCTION/RENOVATION
IN
EXCESS
OF
50% YES 0
NO
0
SURVEY ENCLOSED YES 0
NO
0
'!.';.'
>41~:J'-{'.:1.~~-~!~~;<i!~~·~
~.
DATE
OF
GRANTING
OF
PERMIT
Signature
of
Applicant/Contact Person - Sign & Print
SEPARATE APPLICATION
SHALL
BE
MADE FOR EACH BUILDING
FIELD REPORT ON REVERSE
Rav
08/11
Address
of
Applicant/Contact Person
Telephone
BUILDING
,PERMIT
COMMERCIAL OR MIXED USE PROPERTY
DEPARTMENT OF ASSESSMENT
NASSAU COUNTY
240
Old
Country
Road, Mineola, NY 11501
_________
.,..T_o_w_n
...
,_c_ity,
Village
of;.;;:
=-=---r--===-
;;;;;;;m
ECTION
BLOCK
LOT(S)
SCH
DIST
PERMIT#
ocatlon
N.E.S.W.
SIDE
OF
(OR
CORNER
OF)
N.E.S.W
.
SIDE
OF
f
ulldlng
DATE REC'D
(Assessor
U
se
Only
)
SPECIFIC
ZONING
DESIGNATION
DDRESS
OF
PROPERTY
NAME
OF
BUSINESS
Check one
ITY,
TOWN,
VILLAGE
ZIP
CONTACT
PERSON
----~------
----------
-
----
-------------1
CJowNER
:STIMATED COST OF CONSTRUCTION:
OR
ADDRESS
QLESSEE
CITY,
STATE,
ZIP
•
ATE
TO
BEGIN
PRINCIPLE
TYPE
OF
PHONE
CONSTRUCTION
1ATE
TO
COMPLETE
0
STEEL
EMAIL
OT
SIZE
S.F.
0
------
--------------
--------
------
--1
W
MASONRY
BLDGSON
LOT
0
OTHER
:::r
If
you wish to group or apportion lots, please
ca
ll o
2.
516-571
-15
00
for more information. C
~----------
--------------------------------
....
-----------------------------------------------41
~-·.
)ESCRIPTION OF WORK IN DETAIL (PLEASE PRINT CLEARLY)
--------
------------------------
-------
----'-
---------------------------------
------
--
---t
~
CHECK
ALL
THAT
APPLY
0 NEW BUILDING
0 ADDITION (CHANGE
IN
S.F
.)
0 DEMOLITION
0 ALTERATION
(NO
CHANGE
IN
S.F.)
0 OTHER (Describe)
_______
_...__
0 FA9ADE
0 BASEMENT RENOVATION/ALTERATION
0HVAC
OROOF
0 PLUMBING
0 ELEVATORS
0 SPRINKLERS
osoLAR
OANTENNA
0 BILLBOARD
0 SATELLITE DISH
COMMENTS
SIZE
QUANTITY
USE
BY
SIZE AND
FLOOR
BSMT
1ST
1ST
addnl
use
2ND
UPPER
FLOORS
TOTAL#
FLOORS
EXISTING S.
F.
AREA
Use Size
SF
List additional
use
In
comments section
Residential Use
CO-OP D
CONDO D
RENTAL D
Studio
1BDRM
2BDRM
3BDRM
4
BDRM
OTHER
Describe
Existing
#Units
Existing
Sq. Feet
PROPOSED
S.F.
AREA
Use Size
SF
-----ll(h
Proposed
#Units
----
-11
!
Proposed
Sq. Feet
c;·
=
m
0
n
,r;"
r-
0
-
-
Ill
-
c
I»
'--
--------------------------------------------------------------------------------------------1
.S'
Approved
By
_____________
_
Date
of
Granting
of
Permit'----------
SEPARATE APPLICATION
SHALL
BE
MADE FOR EACH BUILDING
FIELD REPORT ON REVERSE
Rev 08/11
Signature
of
Applicant/Contact Person
Please
Print
Name
'
Tele#
.
Incorporated Village
of
Freeport
FLOODPLAIN DEVELOPMENT PERMIT
(IF YOU RESIDE
IN
A FLOOD ZONE - THIS PAGE MUST BE FILLED IN)
Date:-----------
Application
Number:
Property
S/B/L:
---------
Permit
Number:
Address
of
Property:
------------------
Freeport,
NY
11520
Type
of
Development:
(Check
all
that
apply)
:
Excavation
D Fill D Grading D Residential Addition D Residential Alteration D Pool D Bulkhead D Deck D
Utility Install
or
Replacement D Sewer D Road Construction D Commercial Addition D Commercial Alteration D
Shed I Storage Facility (Must
be
Anchored) D
Roof
D Fence D Oil
Tank
(Must be Anchored) D
DrivewayO
Other (Specify):
OFFICE
USE
ONLY:
FIRM
Data:
Flood Zone:
AE
D
VE
D Map Panel #0238G D 0239G D
Map Panel Date: 09-11-2009
Base
Flood
Elevation
(NA VD) =
so
90
100
110
Development
Standards
Data:
1- Required elevation
of
utilities to
be
installed including but not limited to, air conditioning, electrical equipment, hot water
heaters,
boilers=
Base Flood Elevation (BFE) + 4feet
of
Freeboard = (NAVD) or Not Applicable D
2- Will garage
be
used for any purpose besides parking
of
vehicles, storage, or building access? Yes D
(If
"Yes", then the garage must
be
used in determining the lowest floor elevation)
3-
If
an elevation project, what is the proposed method for elevating the structure?
or
NoD
Fill and Foundation D
No
Fill and Foundation D Pilings D Extend Existing Foundation D Not Applicable D
New Foundation must have required Flood Vent openings installed and quantity
of
vents must
be
provided
at
time
of
application
on
submitted Architectural Drawings.
Engineered
flood
vents
must
be
certified
by
a
Licensed
Design
Professional
and
noted
on
final
Elevation
Certificate.
Total square footage
of
first floor = Sq ft
Total Area
of
Perimeter Flood Vent
openings=
Sq
In.
(Non - Engineered = 1
"per
square foot or the use
of
Engineered vents)
The bottom
of
the openings shall not
be
greater than one foot above either interior or exterior grade at the perimeter
of
the
foundation wall.
4- Commercial floodproofing requires submission
of
Certified Floodproofing Certificate. (Not permitted
in
V Zones)
5-
AE
Zone - Lowest Floor to
be
at
or
above
Base
Flood Elevation (BFE) +4 feet :
Measurement=
(NAVO)
6- V-Zone - Measurement
of
lowest supporting horizontal member must
be
at
or
above Base Flood Elevation (BFE) +4 feet
: Measurement
=
(NA
VD)
7- Regulatory Flood Elevation at development
site=
Base Flood Elevation (BFE) + 4 feet
ofFreeboard
(NAVO)
Applicant acknowledgment: I the undersigned understand that the issuance
of
a floodplain development permit is contingent upon the
above information being correct and that the plans and supporting data have been or shall be provided as required. I also understand that
prior to occupancy
of
the structure being permitted, an elevation and/or floodproofing certificate signed
by
a professional engineer
or
registered land surveyor must
be
on
file with the Village
of
Freeport Building Department indicating the "as built" elevations in relation to
the North American Vertical Datum
of
1988 (NA VD)
Print Name
of
Applicant:
Signature
of
Applicant:
.
.,
Instructions for Completing
617.20
AppendixB
Short Environmental Assessment Form
Part 1 - Project Information.
The
applicant
or
project sponsor is responsible for
the
completion
of
Part
1. Responses
become part
of
the application for approval or funding, are subject to public review, and may be subject to further verification.
Complete Part 1 based
on
information currently available.
If
additional research or investigation would
be
needed to fully
respond to any item, please answer as thoroughly as possible based
on
current information.
Complete all items in Part
1.
You may also provide any additional information which you believe will
be
needed by or useful
to the lead agency; attach additional pages as necessary to supplement any item.
Part 1 - Project and Sponsor Information
Name
of
Action or Project:
Project Location (describe, and attach a location map):
Brief Description
of
Proposed Action:
Name
of
Applicant or Sponsor:
Telephone:
E-Mail:
Address:
City!PO:
State:
I Zip Code:
1.
Does the proposed action only involve the legislative adoption
of
a plan, local law, ordinance,
NO
YES
administrative rule, or regulation?
If
Yes, attach a narrative description
of
the intent
of
the proposed action and the environmental resources that
may be affected in the municipality and proceed to Part 2.
If
no, continue to question
2.
2. Does the proposed action require a permit, approval
or
funding from any other governmental Agency?
NO
YES
If
Yes, list agency(s) name
and
permit or approval:
3.a. Total acreage
of
the site
of
the
proposed action? acres
b. Total acreage to
be
physically disturbed?
acres
c. Total acreage (project site
and
any contiguous properties) owned
or
controlled by
the
applicant or project sponsor?
acres
4.
Check all land uses that occur on, adjoining and near the proposed action.
o Urban o Rural (non-agriculture)
o Industrial o Commercial o Residential (suburban)
o Forest
o Agriculture
o Aquatic o Other (specify):
o Parkland
Page
1of4
-
~
5. Is the proposed action,
NO
YES
NIA
a.
A permitted use under the zoning regulations?
b.
Consistent with the adopted comprehensive plan?
6. Is the proposed action consistent with the predominant character
of
the existing built or natural
NO
YES
landscape?
7.
Is the site
of
the proposed action located in, or does it adjoin, a state listed Critical Environmental Area?
NO
YES
If
Yes, identify:
8.
a.
Will the proposed action result in a substantial increase in traffic above present levels?
NO
YES
b. Are public transportation service(s) available at or near the site
of
the proposed action?
c.
Are any pedestrian accommodations
or
bicycle routes available on or near site
of
the proposed action?
9. Does the proposed action meet or exceed the state energy code requirements?
NO
YES
If
the proposed action will exceed requirements, describe design features and technologies:
10. Will the proposed action connect to an existing public/private water supply?
NO
YES
[If
Yes, does the existing system have capacity to provide service?
ONO
DYES]
If
No, describe method for providing potable water:
11. Will the proposed action connect to existing wastewater utilities?
NO
YES
[If
Yes, does the existing system have capacity to provide service?
ONO
DYES]
If
No, describe method for providing wastewater treatment:
12.
a. Does the site contain a structure that is listed on either the State or National Register
of
Historic
NO
YES
Places?
b. Is the proposed action located in an archeological sensitive area?
13
. a. Does any portion
of
the site
of
the proposed action,
or
lands adjoining the proposed action, contain
NO
YES
wetlands or other waterbodies regulated by a federal, state or local agency?
b.
Would the proposed action physically alter, or encroach into, any existing wetland or waterbody?
If
Yes, identify the wetland or waterbody and extent
of
alterations in square feet or acres:
14. Identify the typical habitat types that occur on, or are likely to be found on the project site. Check all that apply:
D Shoreline
D Forest
D Agricultural/grasslands
D Early mid-successional
D Wetland
D Urban
D Suburban
15. Does the site
of
the proposed action contain any species
of
animal, or associated habitats, listed
NO
YES
by the State or Federal government as threatened or endangered?
16. Is the project site located in the 100 year flood plain?
NO
YES
17. Will the proposed action create storm water discharge, either from point or non-point sources?
NO
YES
If
Yes,
a.
Will storm water discharges flow to adjacent properties?
ONO
DYES
b. Will storm water discharges be directed to established conveyance systems (runoff and storm drains)?
If
Yes, briefly describe:
ONO
DYES
Page
2of4
18. Does the proposed action include construction or other activities that result in the impoundment
of
NO
YES
water or other liquids (e.g. retention pond, waste lagoon, dam)?
If
Yes, explain purpose and size:
19. Has the site
of
the proposed action or an adjoining property been the location
of
an active or closed
NO
YES
solid waste management facility?
If
Yes, describe:
20. Has the site
of
the proposed action or an adjoining property been the. subject ofremediation (ongoing or
NO
YES
completed) for hazardous waste?
If
Yes, describe:
I
AFFIRM
THAT
THE
INFORMATION
PROVIDED
ABOVE
IS
TRUE
AND
ACCURATE
TO
THE
BEST
OF
MY
KNOWLEDGE
Applicant/sponsor name: Date:
Signature:
Part 2 - Impact Assessment. The Lead Agency is responsible for the completion
of
Part 2. Answer all
of
the following
questions in Part 2 using the information contained in Part I and other materials submitted by the project sponsor or
otherwise available to the reviewer. When answering the questions the reviewer should
be
guided by the concept "Have my
responses been reasonable considering the scale and context
of
the proposed action?"
No, or Moderate
small
to large
impact
impact
may may
occur
occur
I.
Will the proposed action create a material conflict with an adopted land use plan or zoning
regulations?
2.
Will the proposed action result in a change in the use or intensity
of
use
ofland?
3.
Will the proposed action impair the character or quality
of
the existing community?
4.
Will the proposed action have an impact on the environmental characteristics that caused the
establishment
of
a Critical Environmental Area (CEA)?
5.
Will the proposed action result in an adverse change in the existing level
of
traffic
or
affect existing infrastructure for mass transit, biking or walkway?
6.
Will the proposed action cause an increase in the use
of
energy and it fails to incorporate
reasonably available energy conservation or renewable energy opportunities?
7.
Will the proposed action impact existing:
a.
public I private water supplies?
b. public
I private wastewater treatment utilities?
8.
Will the proposed action impair the character or quality
of
important historic, archaeological,
architectural or aesthetic resources?
9.
Will the proposed action result in an adverse change to natural resources (e.g., wetlands,
waterbodies, groundwater, air quality, flora and fauna)?
Page
3of4
..
, .
No,
or
Moderate
small
to
large
impact
impact
may
may
occur occur
10. Will the proposed action result in an increase
in
the potential for erosion, flooding or drainage
problems?
11. Will the proposed action create a hazard to environmental resources or human health?
Part 3 - Determination of significance.
The
Lead
Agency
is
responsible
for
the
completion of Part 3. For every
question in Part 2 that was answered "moderate to large impact may occur'', or ifthere is a need to explain why a particular
element
of
the proposed action may or will not result in a significant adverse environmental impact, please complete Part 3.
Part 3 should, in sufficient detail, identify the impact, including any measures or design elements that have been included by
the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact
may or will not be significant. Each potential impact should be assessed considering its setting, probability
of
occurring,
duration, irreversibility, geographic scope and magnitude. Also consider the potential for short-term, long-term and
cumulative impacts.
o Check this box
if
you have determined, based on the information and analysis above, and any supporting documentation,
that the proposed action may result in one or more potentially large or significant adverse impacts and
an
environmental impact statement is required.
o Check this box
if
you have determined, based on the information and analysis above, and any supporting documentation,
that the proposed action will not result in any significant adverse environmental impacts.
Name
of
Lead Agency
Date
Print or Type Name
of
Responsible Officer in Lead Agency
Title
of
Responsible Officer
Signature
of
Responsible Officer in Lead Agency
Signature
of
Preparer
(if
different from Responsible Officer)
Page4
of4
DEPARTMENT
OF
BUILDINGS
OF
THE VILLAGE
OF
FREEPORT, N.Y.
APPLICATION NO.
-------
FILINGDATE
-------
The
fee paid herein shall be non-refundable
and
shall
be
adjusted to refiect
the
actual cost
or
construction
prior
to
the
issuance
of
any Certificate
of
Occupancy
or
Certificate of
Completion. ·
Notice:
It
is the policy of
the
Building Department to cancel
and
destroy any Building
Permit
Application
that
is
not
perfected, abandoned
or
remain inactive for ninety
(90)
days.
Applicant Signature
RESIDENTIAL:
Each
additional
RESIDENTIAL:
Each additional
COMMERCIAL:
Each additional
1st
$1,000.
$1,000.
181'
$1,000.
$1,000.
1st $1,000.
$1,000.
PERMIT FEES
construction fee - - - $150.00 (new building)
- - - - - - - - - - - - - - - $ 10.00
- - - - - - - - - - - - - - - $150.00 (alteration)
- - - - - - - - - - - - - - - -$ 10.00
construction fee - - - $ 300.00 (new
or
alteration)
- - - - - - - - - - - - - - - $ 15.00
$200.00
per
sq
ft
for
new houses, additions, garages, etc
.•.
as
of
1/8/14.
* A $150.00 letter
of
completion fee must be added to
all
Building Permit Applications - except for fences
and
roofs.
FENCES:
New - - - - - -
$ .75
per
linear
ft.
Replacement$ .75
per
linear ft.
OUTDOOR DECKS
& BALCONIES:
$ 48.00
per
square
foot to ascertain cost of construction, then use Residential Fee
for cost
of
the
permit.
POOLS:
Aboveground - - - - - - - - - - - - - - -
$ 150.00
lnground
- - - - - - - - - - - - - - - - - - $ 300.00
* Certificate
of
Occupancy - - - - - $ 150.00
* Temporary C.O. - - - - - - - - - - - $ 300.00
* Amend Duplicate C.O. - - - - - - - $ 75.00
* Letter
of
Completion - - - - - - - - $ 150.00
* Letter
in
Lieu - - - - - - - - - - - - - - $ 113.00
(Must
put
written request
in
for letter
in
lieu, an inspection is required
and
an
electrical survey
must
be submitted before the letter can be issued).
PLUMBING PERMITS:
New construction/alteration - - - -
$ 90.00
for
the 1st (5) fixtures
Additional fixtures - - - - - - - - - - -
$ 7 .50
Gas Test/Gas Burner/Stove - - - - -
$ 60.00
Gas
Water
Heater - - - - - - - - - - - $ 60.00
Gas Unit Heaters - - - - - - - - - - - -
$ 7 .50
DEMOLITION PERMITS:
Frame Residence
$ 300.00
Frame Commercial
$ 600.00
Frame Accessory - - - - - - - - - - - -
$ 150.00
One-story Masonry - - - - - - - - - - -
$ 225.00
A $150.00 letter
of
completion fee must be
added
to all
Demolition Permit Applications.
Page2
SIGN
PERMIT
- - - - - - - - - - - - - $ 150.00
Sign
Renewal-
- - - - - - - - - - - - - - $ 150.00
ELECTRIC
PERMIT
- - - - - - - - S 30.00
RENTAL
PERMIT
FEES:
A)
One
Rental
Unit-
- - - - - - - - - - - - - - $ 150.00
B) Buildings
with
Two Rental Units - - - $ 225.00
C)
Three
Rental
Units - - - - - - - - - - - - - $ 262.00
D)
Four
Rental
Units - - - - - - - - - - - - - - $ 287.00
*PLUS
$ 20.00
FOR
EACH
ADDITIONAL UNIT
EXCESS
OF
FOUR
UNITS -
FEE
NOT
REFUNDABLE.
AIR-CONDITIONING/REFRIGERATION:
Residential - - - - - - - -
$ 75.00
Commercial-
- - - - - - S 150.00
per
unit
plus
$7.50
per
$1,000 cost
of
construction
or
fraction
thereof
for piping, radiators
and
duct
work.
OIL
BURNER/OIL TANK/OIL
HOT
WATER
HEATER
- $ 75.00 (install/remove).
Installation
of
storage
tanks
for flammable liquids - - - $ 300.00
for
the
1st
tank
Each additional
tank
- - - - - - - - - - - - - - - - - - - - - - - - - $ 150.00
installed
on
the
same site
at
the
same time.
STORAGE
TANKS (NON-FLAMMABLE)- - - - -
-$
75.00 (instaWremove).
BULKHEAD
FEES:
New Bulkhead/Add/Replace- - - - - - - - S 300.00 for
the
first
SO
ft.
and
$1.
SO
each
additional foot
*REFACING
OR
RESURFACING BULKHEADS IS NO
LONGER
PERMITTED.
Float,
Ramp
&
Platform
- - - - - - - - - - - - $ lS0.00 each
(Includes docks, piers & boardwalks)
Poles/New/Replacement/Relocate - - - - - - $ 38.00
per
pole
Tie Rods - - - - - - - - - - - - - - - - - - - - - - - -
$ 38.00
per
tie
rod
Finger slips - - - - - - - - - - - - - - - - - - - - - - $ 150.00
per
slip
CODE
COMPLIANCE
- $150.00
*
FEE
WILL
BE
DOUBLE
IF
PERMIT
IS
ISSUED
AFfER
WORK
BEGINS *
Revised 9/08
PLEASE
BE
ADVISED
THAT
A
LETTER
OF
COMPLETION
FEE
WILL
BE
INCLUDED
IN
ALL
BUil.J)ING
PERMIT
APPLICATIONS,
EXCLUDING
FENCES
AND ROOFS.
THIS
CERTIFICATE
WILL
SERVE
THE
APPLICANTS
FOR
THE
PURPOSES
OF
REFINANCING
OR
THE
SALE
OF
YOUR
PROPERTY.
IT
WILL
BE
SENT
TO
THE
PERSON
THAT
IS
PAYING
FOR
THE
APPLICATION
AT
THE
COMPLETION
OF
SAID
PROJECT.
THIS
CERTIFICATE
SHOULD
BE
KEPT
IN
A SAFE PLACE
ANDCANBEGIVENTOYOURTITLECOMPANYOR
REFINANCING INSTITUTION
WHEN
SUCH
TIME
ARISES.
Affidavit
of
Exemption to Show Specific
Proof
of
Workers'
Compensation Insurance
Coverage for a 1, 2, 3
or
4 Family, Owner-occupied Residence
Under
penalty
of
perjury, I certify that I
am
the owner
of
the
1,
2,
3 or 4 family, owaer-occapied residence
(including condominiums) listed
on
the building
permit
that I
am
applying
for,
and I
am
not
required
to
show
specific proof
of
workers' compensation insurance coverage
for
such residence
because
(pleue
check
the
appropriate
box):
0 I
am
performing.
al}
the work.for which the building pennit was issued.
0 I
am
net hiring,
paying
or compensating
in
any
way,
the individual(s) that
is(
are)
performing
all
the
work
for
which
the
building permit
was
issued
or helping me perform such work.
0 I have a
homeownel"S
insurance policy
that
is wrreotJy
in
effect and covers the property
listed
on
the
attached building pennit AND am hiring or paying individuals a
total
of~
than
40
bows
per week
(aggregate hours for all paid individuals on the jobsite) for which the building
permit
was
issued.
I
also
agree
to
either;
+ acquire appropriate workers' compensation coverage
and
provide appropriate proof
of
that
coverage
on
forms
approved
by
the Chair
of
the NYS Workers' Compemation Board
to
the government entity issuing
the building
permit
if
I need
to
hire
or
pay individuals a total
of
40 hours or more per week (aggregate hours
for
all paid individuals on the j obsite) for work indicated on the building
permit,
or
if
appropriate.
file
a C£.
200
ex.emption
form;
OR
+ have the general contractor. performing the work on the
1,
2, 3 or 4 family, owner-occapied residence
(including condominiums)
listed on
the
building
perm.it
that I am applying fur,
provide
appropriate
proof
of
worlcers
• eompensation coverage or proof
of
exemption
from
that
coverage on
forms
approved
by
lhe
Chair
of
the
NYS
Workers' Compensation Board
to
the government entity issuing the
building
permit
if
Che
project takes a total
of
40 hours or more per week (aggregate hours
for
all paid individuals
on
the
jobsite) for
work indicated
on
the building permit
(Signature ofHomeowner)
{Homeowner's Name
Printed)
Property
A~
that
requires
the
building permit:
(Da
te
Signed)
Home Telephone Number
-------
'
I
!
~
1
:
"""(C.,...0-,...,...,.=ty-C""lr-e-,rk..-or_.,..,N.,...o~.,,..•-ry........,P•"""'b...,llT""c)....---
j
I
I
Once
aotariled,
dJfa
Bl'·l
form serves
a1
an exempdoa
!or
bodl worken' co111peua1lo
aad
dtsabDit)'
beadill
inslll'Uaecava"8p.
BP-I
(12/08)
NY-WCB
Letter from the
~hair
of
the WorketS' Compensation Board
October 27, 2008
Dear
Government
Official:
Workers'
compensation
law (WCL) requires
the
beads
of
all
municipal
and
state
entities
to
ensure
that
businesses applying
for
pennits,
licenses,
or
contracts have
appropriate
workers'
compensation
and
disability benefits
insurance
coverage. This
requirement
applies
to
both
original issuances
and
renewals,
whether
the
governmental
agency is having
the
work
done
or
is
simply issuing
the
permit,
license
or
contract.
An
instruction
manual
that
will
further
clarify
the
requirements,
including
instructions
for
a
new
CE-200
exemption
form
that
becomes effective
on
Dec.
1,
2008,
is available
to
download
at
the
Workers'
Compensation Board's website, www.wcb.state.ny.us.
Once
you
are
on
the
website, click
on
Employers/Businesses,
then
Business Permits/Licenses/Contracts; from
there, click
on
bzstruction Manual
for
Businesses Obtaining Permits/Licenses/Contracts.
Government officials
without
access
to
the
web
may
call (518)
486-6307
to
have
a copy
of
this instruction
manual
mailed
to
them.
I encourage you to
obtain
one
for
your
reeords.
Also included
in
the
instruction
manual
is a copy
of
General Municipal
Law
Section 125
that
requires
all applicants
to
provide
proof
of
workers' compensation compliance
when
applying for a Building Permit.
Ensuring
that
businesses
receiving
permits,
licenses
or
contracts
from
municipal
and
state
agencies comply with
the
WCL protects
both
injured
workers
and
employers.
In
addition,
such
oversight helps to level
the
playing field,
by
strictly enforcing
the
requirement
that
all
businesses
maintain
mandatory
insurance
coverage. Municipal
and
state
agency cooperation is a
critical
component
of
encouraging
business
compliance.
Please note
that
ACORD
forms
are
NOT
acceptable
proof
of
New
York
State
workers'
compensation
or
disability benefits insurance coverage.
Fonn WC/OB
..
100 Will Be Retired
Form
WC/DB-100, currently
used
to
demonstrate
exemption from workers'
compensation
and/or
disability benefits
insurance,
will
be
retired
on
Dec.
1,
2008.
Accordingly,
a WC/DB-100
stamped
prior
to Dec.
1,
2008
cannot
be
used
as
proof
of
exemption
for
new
or
renewed permits, licenses
or
contracts
issued
by
government
agencies
after
that
date.
Instead,
Form
CE-200, which replaces
Form
WC/DB-100,
must
be
used
for
applicants seeking
exemptions starting
on
Dec.
1,
2008.
New
Form CE-200
Form
CE-200
reflects a new
process
for
granting
exemptions
from
workers'
compensation
and
disability benefits
insurance
coverage
requirements
. Historically,
the
WC/DB-100
exemption
forms
were
valid
for
multiple permits, licenses
or
contracts
where
the
applicant applied,
had
to
be
notarized,
and
had
to
be
stamped
by
the
New York State Workers'
Compensation Board.
Effective Dec.
1,
2008,
this process will change.
Bxenmt:ions
will
no
longer be valid for
multiple
permits,
licenses
or
contracts
for
which
the
applicant applied.
Further
, exemptions
no
longer
have
to
be
notarized,
nor
do
they
have to
be
stamped
by
the
NYS
Workers'
Compensation
Board.
(Govern~ent
agencies
may
continue
to
use
insurance
and
self-insurance certificates
for
multiple
permits,
licenses
or
contracts
issued
to
a specific legal
entity
during
the
coverage period
listed
on
insunfnce/self-insurance
related
certificates).
-3-
Prove
It
to
Move
It
The Prove
It
to
Move
It
Program
Workers' compensation
law
(WCL)
requires the
heads
of
all municipal and state entities
to ensure
that
businesses applying
for
pennits, licenses, or contracts carry workers' compensation
and disability benefits insurance.
This
requirement applies to
both
original issuances and
renewals, whether the governmental
agency
is
having the
work
done or
is
simply issuing
the
permit, license or contract.
Verification
of
insurance
is
necessary
to ensure benefits are available, should
workers
get
injured.
It
also
levels the playing field
for
honest businesses, because they are less likely to
be
Wldercut
by
unscrupulous employers
who
gain a cost advantage by not canying insurance.
Enforcing these provisions
of
the
law
contribute
to
the betterment ofNew York's
economic
climate. Municipal and
state
agency
cooperation
is
a critical component
of
encouraging business
compliance.
This instruction
manual,
Provg
It
to
Move
b.
will
further clarify the requirements. Under
the
Prove
It to Move It program, applicants must prove compliance with
NYS
workers'
compensation and disability benefits requirements
to
move their government pennit, license or
contract along the approval process. This program reflects requirements under
Woikers'
Compensation
Law
§57
and §220(8), and General Municipal Law § J
25.
1be
Prove
It
to
Move
It
illstnlction manual formally names the program that has
been
in
pl.ace,
by
statute, since
1922.
Nothio1 bas changed in enforcing this program since the last instruction manual was
issued
ill
December, 2008. However, based on requests
from
government agencies, this manual
reflects
more
comprehensive instructions on the program's requirements.
Government officials without
access
to
the
web
may
call (518) 486-6307
to
have a
copy
ofthis instruction manual mailed
to
them.
Also included in the instruction
manual
is
a
copy
of
General Municipal Law Section
125,
which
requires
ail
applicants
to
provide proof
of
workers' compensation compliance
when
applying for a Building Permit.
Form CE-200 -
Affidavit
of
Exemption
Form
CE~200
reflects the process for granting exemptions
from
workers' compensation
and disability benefits insurance coverage requirements.
Applicants eligible for exemptions must file a new c&-200 for each
and everv
nm
or
renewed
oermit. license
or
contract
is.sued
by a government
agency.
Each
CE~200
will
specifically list
the issuing
govt'Jlllllent
agency
and
the specific type
of
permit, license or contract
requested by the applicant. Applicants for building
pennits will also need
to
supply
additiona1
information including identifying the specific job location and
the
estimated cost
of
the project.
Please
ensW"e
that Fonn
CE-200
is
signed and
dated
by
the
applicant
and
that your
specific governmental
agency
is listed. CE-200 forms
are
ONLY valid
for
the government
agency listed on
Form
CE-200.
The reason
that a business is exempt
from
workers' compensation and/or disability
benefits will be clearly stated on Fonn CE-200. Based on their knowledge
of
the applicant's
business.
governl.Jlent
agencies must verify
that
the business
is
eligible for the workers'
compensation and/or disability benefits
ex.emption
reason described on
the
CE-200, and notify
the Board's investigative staff
if
there are discrepancies. Phone numbers for Board investigative
staff are located
on
page 10
of
the instruction
manual.
~
New
York
State Workers' Compensation
Board
-
December,
2011
4
Prove
It
to
Move
:
It
Each cg.200 will have a certificate number printed on it. You can verify
if
the
CE-200
provided
to
you
by
the applicant
was
actually i$Ued by the Workers' Compensation Board's
computer system
by
checking
on
the Board's
website
at
the
following
URL:
http:
//www.wcb.ny.gov/content/ebiz/wc db exemptions/verifvCE200Qyerview.jsp.
The majority ofCE-200 fonns
will
be
processed electronically. Applicants
will
be
able
to
fill out the
CE-200
on-line
and
upon completion,
immooiately
print out a copy
of
the
CE-200
that
they
will
then submit to the government agency issuing the permit, license or contract. Computers
with internet access are available
for
CE-200
electronic application processing Ill: Customer
Service Centers located
in Workers' Compensation Board Offices across the state. Applicants
without access to a computer
may
obtain a paper application
by
writing or visiting
any
Workers'
Compensation
Board
district office, or
by
calling 866-298-7830. Applicanta are strongly
encouraged
to use
the
Board's electronic web program. They can receive
their
Form CE-
200 immediately, whereas manual
~aper
(illag may take
up
to four
weeks
to
process.
Please see pages
11-14
for
more
infonnation on
Form
CE-200.
Other Important Highlights
of
the Prove
It
to
Move
It
Program
An
ins~ction
sheet on page 6
of
the instruction
manual
may
be
copied
by
municipal
and
state agencies
as
an
insert
in
their application packages
for
government issued permits, licenses or
contracts. This
sheet
describes all
the
required forms
of
this program and where applicants
may
obtain these
forms.
Please
note that ACORD forms
are
NOT acceptable
proof
of
New York State workers'
compensation or disability benefits
insurance
coverage.
This manual identifies the specific forms that govenunent agencies can
accept
to enforce
these sections
of
the Workers' Compensation Law and where applicants
may
obtain those fonns.
No
other forms are acceptable as proof of com.pliance
with
New
York
State workers'
compensation or disability benefits.
Please ensure that the legal entity
name
and
the Federal Employer Identification
Number
(FEIN) on certificates
of
insurance, self-insurance,
or
attestation for exemption exactly matches
the
legal
entity
~e
and
FEIN
of
the applicant applying
for
the permit, license or contract that
you
are
issuing.
Form
BP-I, found on page 30, is the only
form
that municipal and state agencies
may
now
reproduce themselves
and
distribute
as
part
of
this
process.
Please notify the permit-issuing, license-issuing and contract-making agencies or
departments within your jurisdiction
of
these
requirements so that they
may
comply with
the
Workers' Compensation
Law.
If
you have
any
questions or require additional information, please
call
the
Board at ( 518) 486-6307.
New
Yori<
State
Workers' Compensation
Board
-
December,
2011
5
Prove
It
to
Move
It
May,2010
Workers' Compensation Requirements
under
Workers' Compensation
Law
§57
To
comply
with coverage provisions
of
the Workers' Compensation Law (WCL), businesses must:
a)
be
legally exempt
from
obtaining workers' compensation insurance coverage; or
b)
obtain such coverage
from
insurance carriers; or
c)
be
a Board-approved self-insured employer; or
d) participa!e in
an
authorized
group
self-insurance plan.
To assist State
and
mu.qicipal
entities in enforcing
WCL
Section 57, businesses requesting permits or licenses, or
seeking to enter into contracts
MUST
provide
ONE
of
the following fonns to
the
government entity issuing the
permit or entering into.a contract:
A)
Fonn CE-200. Cerlificate
of
Attestation
of
&emption from NYS
Workers
' Compensation and/or Disability Benefits
Coverage;
Form
CE-200
can
be
filled out electronically
on
the Board's
website,
www.wcb.ny.
gov.
Click on the
button
entitled
"WC/DB Exemptions Form CE-200" (In bright yellow letters). Applicants filing electronically arc able
to
print a
finished Fonn CE-200 immediately
upon
completion
of
the electronic application. Applicants without
access
to
a
computer
may
obtain a paper application
for
the
CE-200
by
writing or visiting
the
Customer Service Center
at
any
district office
of
the Workers' Compensation Board. Applicants using the
manual
process
may
wait up to fom
weeks
before receiving a CE-200. Once the applicant receives the CE-200, the applicant can then submit that
CE-200
to
the
government
agency
from
which
he/she
is
getting the pemtlt, license or contract; or
8)
Form
C-105.2, Certificate of Workers' Compensation Insurance (the business's insurance carrier
will
send
this
form
to the government entity
upon
request). Please
NGte:
The State Insurance Fund provides
its
own version
of
this fonn,
the U-26.3; or
C)
Form Sl-
12,
Certificate
of
Workers
' Compensation Self-Insurance (the business calls
the
Board's Self-Insurance
Office at
518-402-0247},
or GSI-105.2, Certificate
of
Participation in Worker's Compensation Group Self-Insurance
(the
busines
s
's
Group Self-Insurance Administrator
wil1
send this fonn
to
the government entity
upon
request).
Disability Benefits Requirements
under
Workers' Compensation
Law
§220(8)
To
comply
with covenige provisions of the
WCL
regan:fing
disability
bene
fi
ts, businesses
may
:
a)
be
legally exempt
from
obtaining disability benefits insurance coverage; or
b)
obtain such coverage
from
insurance carriers; or
c)
be
a Board-approved self-insured employer.
Accordingly, to assist State and municipal entities in enforcing
WCL
Section 220(8), businesses requesting
permits
or
licenses, or seeking
to
enter
into
contracts
mmt
provide
one
of
the following
forms
to
the
entity
issuing
the
pennit or
entering
into
a contract:
A)
CE-200.
Certificate
of
Attestation
of
Exemption
from
NYS
Workers' Compensation and/or Disability Benefits
Coverage
(see
above);
B)
DB-120.1, Certificate
of
Disability Benefits Insurance (the business's insurance carrier
wiU
send this fonn to the
government entity
upon
request);
or
C)
DB-155,
Certificate
of
Disability Benefits
Se/f-!nsuTance
(the business calls the Board's Self-Insurance Office
al
518-402-0247).
NYS
Agencies Acceptable Proof: Letter
from
the
NYS
Department
of
Civil Service indicating the applicant is a
New
York
State governmenf agency covered
for
workers' compensation under Section 88-c
of
the Workers'
Compensation
Law
and exempt from
~S
disability benefits.
Please note that for
bolldiog
permits
only, certain homeowners
of
I, 2, 3 or 4 family owner-occupied
residences
serving
as
their
own
G~neral
Contractor
may
be
eligible
to
file Form BP-I (The homeowner obtains this
form
from
either the Building
DeJ?artment
or on the Board's website, J!ttg;//www.wcb.ny.gov/content/main/formslbp-1.pdf)
New
Yor1<
State
Workers' Compensation
Board
-
December,
2011
6
..
IQ:
ALL
BUILDING
PERMIT
APPLICANTS
FROM
: INC.
VILLAGE
OF
FREEPORT
BUILDING DEPARTMENT
SJJBJECT:
ELECTRIC
DEMAND AND REQUIREMENJ'S
l!!B:
NEW
BUILDINGS (RESIDENTIAL
AND
COMMERCIAL)
MAJOR
RENOVATIONS
TO
COMMERCIAL
BUILDINGS
·················
·
···················~···································
Due
to
the necessity
of
providing adequate service to all residents
of
the
Village, it will now be necessary
to
submit a letter
from
the Electric
Department prior to submitting a Building Permit Application. Please
contact Lester Endo, Jr. at 516- 377-2235
in
order to obtain
same.
..
. '
TO:
FROM:
All Bullding
Permit
Applicants &
Phunben
Inc. Village
of
Freeport
Building
Department
SUBJECf:
Water
Production
Cap
Due
1o a
water
production
cap imposed
on
the
VDJage
of
heeport
by
the
N.Y.S.
Department
of
Environmental
COJUuvation (DEC)
any
of
tbe
following bulldina permit
applfcaUons
ud
plumbing
applicatio••
d
pot
be
aQ:tipted In
dlll
office unless
aecompoled
by
a
m:fttm
sommitmenf
from
the
Water
Department
that
said
project
will
be connected
to
the
water
syrtem.
1.
Any
new
construction
requiring
water
semce (homes, condos, offices,
factories,
etc.}
Z.
Bathroom
renovations.
3. Addftions
or
alterations
whJch
contain
plumbing.
4. Swimming pools,
hot
tubs, jacll22is.
S.
Any
pennJta
which,
ill
the
opinion
of
the
Superintendent
of
Buildinp,
wm
require
additional
water
usage.
INFORMATION
QOYJRED
BEFORE
AN
ISSUANCE
OF
A
LETER
Of
WAUR
AVAH,qn,rrv.
Draft
a
letter
to
Water
&
Sewer
Services.
In
the
letter
state
the
address
of
premises
undergoing
renovation
and/or
constniction.
State
nature
of
renovatio.n.
If
it
includes renovation
or
addition
of
a
bathroom,
illclude
in
letter
11
that
all
fixtures
vesl
wfil be
of
the
water
savinp
type
and
toilets
will
be low
fluh
lgs
that
1.6
ganom
per
fhuh."
Indicate
also
if
any
whhlpools
are
to be
wed.
For
ldtclaen
renovation, indicate
nature
and
water
savings type fixtures.
For
pooJs, indicate
in
the
ground
or
aboveground pool;
siie
of
the
pool
and
totaJ
gallon capacity.
For
sprinkler
syatem.s,
call
Water
and
Sewer
Services 377-2379.
For
new homes,
submit
plans
and
indicate various uses
of
water.
(Enmples,
numl>er
of
toilets,
slab,
showen,
etc.)
Also, request
will
be
for
a 1" domm:Jc tap.
Using dUt format,
mail
the
letter
to
Water
and
Sewer
Services, 46
N.
Ocean Ave.
Freeport, New
York
11520.
..
BE
SAFE
NO POOL PERMIT APPLICATION WILL BE ACCEPTED
UNTIL A
FREEPORT
LICENSED ELECTRICIAN HAS
FILED FOR
THE
ELECTRICAL SERVICES FOR POOL.
A U.L. APPROVED POOL ALARM MUST BE INSTALLED.
NO
POOL PERMIT
WILL
BE FINALIZED, AND
NO
POOL
SHALL
BE
USED WITHOUT
THE
INSTALLATION
OF
A
POOL ALARM AND INSPECTION
BY
THIS
DEPARTMENT THEREOF.
FAILURE
TO
COMPLY
WITH
ANY
OF
THE
ABOVE
ELECTRICAL
OR
POOL
ALARM
REQUIREMENTS,
WILL
RESULT IN AN
APPEARANCE
TICKET
BEING ISSUED AND MAY
BE
PUNISHABLE
IN
VILLAGE
COURT
FOR
A
FINE
UP
TO
$1,000.00.
.'I<
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