PERMITS
FOR:
1. Bulkheads
2. Floats ,
3.
Finger
Slips
4. Filings
5.
Other
misc. marine s
tructure
s
NOTE: You
a~e
to contact
appropriate
Town, State and/
or
Federal government officials to ensure
that
the subject
work
is
performed in compliance with
their
requirements.
Fa
ilure to
do
so may
subject you to enforcement action
under
Town, State
and/or
Federal Law.
I.
Department
of
Conservation
and
Watenva
ys - Box 180
Lido Blvd.
Point Lookout,
NY
11569
(516) 431-9200
Fax:
(516) 431-0088
2. U.S.
Army
Corps
of
Eng
ineers
26 Federal Plaza
Permit
Division
New York,
NY
102278
(917) 790-8511
Fax: (212) 264-4260
3. N.Y.S. Dept.
of
Environmental Conservation
Building #40, SUNY
Campus
Permit
Division
Stony
Brook
, NY
11
790
(631) 444-0365
Fax:
(631) 444-0360
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
Incorporated Village
of
Freeport
FLOODPLAIN DEVELOPMENT P
ERMI
T
Date: _ _ _
______
_ _
Application Number:
Property
S/B/L:
____
_ _ _ _ _ _
Perm
it Nu
mber
:
A
dd
ress
of Property: _ _
____
_ _ _ _ _ _ _
______
F
reep
ort
,
NY
11520
I ype of Deyelopmept: (Ch
eck
all th
at
appl
y):
Ex
cav
ation D
Fill
0 Grading 0 Residenti
al
Addit
ion
0
Re
sidential Alteration 0 Pool 0 Bulkhead 0 Deck 0
Utility lnstall
or
Replacement 0 Sewer 0 Road Construction 0 Commercial Addition 0 Commercial Alteration 0
Shed I Stora
ge
Fa
cility (Must be Anchored) 0 Roof 0 Fence 0
Oi
l Tank (Must be Anchored) 0
Driveway 0
Other (Speci
fy
):
OFF
I
CE
USE
ONLY;
F I
RM
Da
ta
; Fl
oo
d Zone: AE 0
VE
0 Map Panel #0238G 0 0239G 0 Map
Pan
el Date:
09-1
1-2009
Base F lood El
eva
t
io
n (NA
VD)
=
80
90
100
110
Qcyelopment Stan
dar
ds D
ata
;
1- Required elevation
of
utilities to be installed
in
cluding but not limited to, air conditioning, electrical equ
ipm
ent,
hot
water
heaters, boilers = Ba
se
Flood Elevation (BFE) + 4feet
of
Freeboard = (NA VD) or Not Applicab
le
0
2- Will garage be used
for
any purpose besides parking
of
vehicles, storage, or building access?
Yes
D
or No 0
(If "Yes", then the garage must
be
us
ed
in
determining the lowest floor elevation)
3-
If an elevation project, what
is
th
e proposed
met
hod
for
elevating the structure?
Fill and Foundation
0 No
Fill
and Foundation 0 Pilings 0 Extend Existing Foundation D Not
Ap
pli
cable D
Ne""
Foundation mu
st
ha
ve
required
Fl
ood Vent openings installed and quantity
of
ve
n
ts
must
be
provided
at
ti
me
of
application
on
submitt
ed
Archi
te
ctural Draw
in
gs. Engineered l
lood
ve
n
ts
must be cert
ifi
ed by a Licensed D
es
ign
Profes
sional
and
noted on
fi
nal Elevation
Ce
rtificate.
Total squ
ar
e
foo
ta
ge
of
first floor Sq
ft
Total Area
of
Peri
met
er Flood Vent
op
enings =
Sq
In
.
(Non - Eng
in
eered = I "per square foot or the use
of
Eng
in
eered vents)
The bottom
of
the openings shall not
be
greater than o
ne
foot above either interior or exterior grade at the perimeter
of
the
foundation wall.
4-
Commercial floodproo
fin
g requires submission of Certified
Fl
oodproofing Certificate. (Not permitted
in
V Zones)
5-
AE Zone - Lowest Floor to
be
at
or above Base
Fl
ood Elevation (BFE) +4 feet : Measurement = (NA VD)
6-
V-Z
on
e - Meas
ur
ement
of
lowest supporting hori
zo
ntal member must
be
at or
ab
ove Base Flood
El
evation (BFE) +4 feet
: Measurement = (NA VD)
7-
R
eg
ulatory Flood Elevation at development s
ite=
Base Flood Elevation (BFE) + 4 feet
of
Freeboard
(N
AVO)
Ap
plic
an
t
acknowledgment:
I t
he
undersigned
understand
that
th
e
issuance
of
a
floodplain
development
permit
is
contingent
upon
the
above
information
be
ing
correct
and
that
the
plan
s
and
su
pporting
dat
a
have
been or
shall
be
p
rovide
d as require
d.
I
also
und
e
rstand
that
prior to
occupancy
of
the
structure
being
permitted, an elevation
and/or
floodproofing certificate
signed
by
a pr
ofessional
engineer or
r
eg
istered l
and
surveyor
must
be
on
file
with
th
e Village
of
Fr
eep
ort
Building
Dep
a
rtment
indicating
th
e
"as
built
"
elevations
in
relation
to
th
e
North
Amer
i
can
Vert
i
ca
l
Datum
of
1
988
(NA
VD)
Print Name
of
Applicant: _ _ _ _ _
______
_ Signature
of
Applicant:
.
,.,...
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
'--
--------------------------------------------------------------------------------------------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#
.
BUILUINu
PERMI r
PUBLIC UTILITY
DEPARTMENT OF ASSESSMENT
NASSAU
COUNTY
240
Old Country Road, Mineola,
NY
11501
DA
TE REC'D
N
~
2
Cl
(")
!;:
Sec / Blk
/l
ot
Cll
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NASSAU COUNTY
US
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OF
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NAME
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BU
SINESS/CONTRACTOR
L
oca
tion
,
ADDR
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SS
OF
PROPERTY
Check one
CITY,
TOWN
, VILLA
GE
ZIP
CONTACT
PERSON
D
6
O
WN
ER
Ow
ner
of
Property
OR
~A
~O~D~R
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-------------
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LESSEE D
CITY, STATE, ZIP
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NA
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Public Utilities
Cellular Communications (Wireless)
Public Utilities
Carrier Mounting Arrngmt
Electrlc
AT & T
ROOF
Pipelines M
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MONO
POLE
Private Water Co. Nexlel SATELLITE DISH
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LATI
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TOWER
;JI;
Oth
er Olher
Tanks Concrcle
ga
l.
POWER PLANT
D
Fuel Typ
n:
Na
lur11I
Gas
Oleul
F
uel
Turbi
ne
Oth
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Water
Stee
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TYPE
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Fuel
Alum
i
num
gal.
Mode
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on
Fiberglass g
al.
O
th
er Olher
Capac
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gal.
D
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ATE
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SP
ECIFICATIO
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:
D
PR
EFAB
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NOTES:
1--~~~...,.....i..~~~~'--~~~~~~.....::c...-1--~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~
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~--1Sl
D
NEW
BUILDING
0
AOOITION
0
DEMOLITION
0
INTERI
OR
or
EX
TERIOR
ALTERATION
D
AIR
CO
NDITI
ON
ING I
HV
AC
D
R
OOF
D
RE
TIREMENT
OF
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0
BACKI."
GENERATOR KVA:
0
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(OC><:nbe)
:
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---~-------------------
..._
-----------~~~~~~~~~~-~~~~~-
~--10
~
1----~--
~------~--------~-------------~~~---~---~~~~~-
---t
m
SE
PARATE
APPLICATION SHALL
BE
MAD
E F
OR
EACH BUILDING
Sign1tu10
ol A.PQlicantlContad
Pc
rs.oo
DATE OF GRA
NTI
NG
OF PERMIT
FIELD REPORT
ON
REVERSE
Add1oss of ApplicanUContaet
Po"4n
Rev. 08/11
Instructions for Completing
Short Environmental Assessment Form
Part I -Project Information
Part
I - Project
In
forma
ti
on. The
ap1>licnnt
or
(lroject
s1>onsor
is
responsible for the completion
of
P:1rt
I.
Responses become part
of
the
applic
at
i
on
for approval
or
funding,
arc
subject to public review, and may be subject to further verification. Complete Part I based
on
information currently available.
If
additional r
esea
rch
or
in
vestigation \vould be needed to fully respond to any item, please answer
as
thoroughly
as
possible based
on
current information.
Complete all items
in
Part I. You may also provide any additional information which you believe will be needed by
or
useful to the
l
ead
agency; attach additional pages
as
necessary to supplement any item.
Part
I -
Project
and
Spo
n
sor
Information
Name
of
Action
or
Pr~ject:
Project Location (describe, and attach a loc
at
ion map):
Brief Description
of
Proposed Action:
Name
of
Applicant
or
Sponsor:
Telephone:
E-Mail:
Address:
City/PO: State:
I Zip Code:
I.
Does the proposed action only involve the legislative adoption
of
a plan, lo
ca
l law, ordinance,
administrative rule,
or
regulation?
NO YES
If
Yes, attach a narrative description
of
the intent
of
the proposed action and the environmental resources that
D D
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
government Agency?
NO YES
If Yes, list agency(s) name
and
permit
or
approval:
D D
3.
a. Total acreage
of
the site
or
the proposed action?
acres
b. Total acreage to be physically disturbed'?
acres
c. Total acreage (project site and any
cont
iguous properties) owned
or
controlled by the applicant
or
project sponsor? acres
4.
Check all land uses that occur on,
are
adjoining
or
near the proposed action:
5.
D Urban
D
Rural (non-agriculture)
D
Industrial
D
Commercial D Residential (suburban)
D Forest
D
Agriculture
D
Aquatic
D
Other(Speci
fy
):
D Parkland
Page
I oJ 3
SEAF 2019
5. Is the p
ropos
ed action.
NO
YES
NIA
a. A permitted
use
und
er
th
e
wning
regulations?
D D
D
b.
Consistent with
the
adopted comprehensive plan?
D D
D
NO YES
6.
Is the proposed action consistent with the predominant character
of
the existing built or natural landscape'?
D D
7. Is t
he
site
of
the prop
ose
d action located in, or does
it
aqjoin. a state
li
sted Critical Enviro
nm
ental Area?
NO
YES
If
Yes, identify:
D D
NO
YES
8. a.
Will
the
prop
osed
action r
es
ult
in
a substantial
in
crease in traffic
above
present l
eve
l
s?
D D
b.
Are
public transportation
serv
ices
ava
ilable
at
or
n
ea
r the site
of
the proposed action?
D D
c.
Are
any
pedestrian accommodations
or
bicycle routes available on
or
near
the
site
of
the proposed
D
D
action?
9.
Does
the
proposed action m
ee
t
or
exceed the state energy
code
requirements?
NO YES
If
th
e proposed action will
exceed
requirements, describe design featu
res
and
technologies:
D D
10.
Will the proposed action
co
nnect to an existing public/priv
at
e water supply'?
NO YES
If
No
, describe method for providing potable water:
D D
11.
Will the proposed action connect
to
existing
wastew
at
er utiliti
es?
NO YES
If No, describe
meth
od
for providing wastewater treatment:
D
D
12
. a. Does the project site contain. or is it substantially contiguous to, a building, archaeological site.
or
district
NO YES
which is listed
on
the
Nation
al or St
ate
Register
of
Histo
ri
c Places,
or
that has been determined by the
D D
Commissioner
of
the
NY
S Office of Parks, Recreation
and
Histo
ri
c Preservation to be eligible for listing on
th
e
State
Reg
ister
of
Historic Places?
b. Is
the
project site, or
an
y
po
rti
on
of
it, located in
or
adjace
nt
to an
are
a designated
as
sensiti
ve
for
D
D
archaeological sites on
the
NY
Sta
te Historic Pr
ese1vatio11
Office (SHPO)
ar
chaeologica l site inventory?
13. a. Does
any
portion
of
the site
of
the proposed action,
or
l
ands
adjoining the proposed action,
co
ntain
NO
YES
we
tlands
or
ot
h
er
waterb
od
i
es
regulated by a federal, state or local agency?
D D
b. Would
the
propo
sed action physically alter,
or
encroach into, any existing wetland
or
wat
erbo
dy
'?
D D
l
fYcs,
identify the wetland or waterb
ody
and extent
of
alterations
in
square feet
or
acres:
Page
2 o/'3
14.
Identify the typical habitat types that occur
on,
or
are likely to be found on the project site. Check all that apply:
0Shoreline
0 Forest 0 Agricultural/grasslands D Early mid-successional
Owetland
D Urban D Suburban
15. Does the site
of
the proposed action contain any species
of
animal,
or
associated habitats, listed by the State
or
NO YES
Federal government as threatened
or
endangered?
D
D
16.
Is the project site located
in
the I 00-
ycar
flood plan?
NO YES
D D
17. Will the proposed action create storm water discharge, either from point
or
non-point sources?
NO YES
If
Yes,
D
D
a.
Will storm water discharges flow to adjacent properties'?
D D
b.
Will storm water discharges be directed to established conveyance systems
(runoff
and storm drains)?
If
Yes, briefly describe:
D
D
18.
Does the proposed action include construction
or
other activities that would result in the impoundment
of
water
NO YES
or
other liquids (e.g., retention pond, waste lagoon, dam)?
If
Yes, explain the purpose
and
size
of
the impoundment:
D D
19.
Has the site
of
the proposed action
or
an adjoining property been the location
of
an acti vc
or
closed solid waste
NO YES
management facility?
If
Yes, describe:
D
D
20.Has the site
of
the proposed action
or
an adjoining property been the
su~ject
of
remediation (ongoing
or
NO YES
completed) for hazardous waste?
If Yes, describe:
D
D
I
CERTIFY
T
HA
T
THE
INFORMATION
PROVIDED
ABOVE
IS
TRUE
AND
ACCURATE
TO
THE
BEST
OF
MY
KNOWLEDGE
Applicant/sponsor/name: Date:
Signature:
Title:
PRINT FORM
Page
3
of
3
PERMIT
FEES
Page2
SIGN
P
ERM
rr
-------------$ 150.00
Sign
Renewal---------------$
150.00
F.LF.CTRIC
PERMIT--------$
30.00
RE
N
TAL
PEIUvllT f-EES:
A)
OncRcntalUnil---------------
Sl50.00
B)
BuildingswithTwoRental
Units---
$225.00
C)
Three
Rcnt31 U
nits
- - - - -
--
-
--
- - - $ 262.00
D)
Four
Rental
Units-------
-------
S287.00
*PLUS
S20DO
FOR
EACH
ADDITIONAL
UNIT
EXCESS Or-FOi
JR
I
JN
ITS-FE
E
NOTREFUNDJ\l~LE.
AIR-CONDITIONJNG/REFRIGERATION:
Residential - - - - -- - - S 75.00
Commercial -
----
--
$
150.
00
per
unit
plus
$7.50
per
$1
,
000
cost
of
construction
or
fraction
thcrcor
for piping. radiators and duct
work.
OIL
BURNER/
Oii
, T,:\NK/
OIL
HOT
WATER H
b\TER
-$75.00(install/rcmovc).
lnswllationol'storagctanks
forllammahk:
l
iq
uids
---
S300.00 fort
he
I
sltank
Each
additional
tank-------------------------$
150.00
installed
on
the
same
s
ilo..~
at
the
s
ame
time.
STORAGE
TANKS
(NON
-FL/\M
MAl3U'.) -----
-s
75.00 (install/
remove).
BULKHEAD
FEES:
New
Bulkhead/
Add
/
Replace
----
---
- S 300.00
for
the
lirst
50
fl..
and
$I
SO
each
additional foot
*
RE
FACl
l\G
OR
Rl
~
SURF1\CING
IS
U
LKHEADS
IS
NO
I.ONG
ER
PERMllTED.
Float, Ramp& Plalforrn
------------S
150.00cach
(Includes
doc
ks. piers & boardwalks)
Poles
/
New
/Rcplaccmcnt/ Rclocatc - - - - -
-S
38.00
per
pole
Ti
e Rods - - - - - - - - - - - - -
--
- - - - - - - - - S 38.00 per tie rod
Fi
ngcr slips - - - - - - - - - - - - - - - - - - - - - - s
150.00
per
~Ii
p
CODE
COMPLIANCE
-$150.00
*
FCE
WILL
BE
DOUBLE
IF
PER
MIT
IS ISSUED AFTER \YORI< BEGI
NS
"'
Re
vised
I /09
DEPARTMENT OF BUILDINGS
OF
THE
VILLAGE
OF
FREEPORT,
N.Y.
APPLICATION
NO
.
----------
FILING
DATE
----------~
The
fee
paid
herein
shall
he
non-refundable.
Said
cost
wi
ll
be
for
the
processing
of
the
app
lication
whether
approved
or
not.
D O\:VNER
OH
LESSEE
D
CONTl~ACTOR
D
ARCHITECT
OR
ENGINEER
A Pr>licant
Name
Ap(>licant
Signature
State
of
New
York
County
of
Nassau
0
OTHER
(must
spcci(y)
Sworn
to
before
me
on
this
__
_
day
of
_______
, 20
__
Notary
Public
----------~
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