STATE OF NEW YORK
COUNTY OF WESTCHESTER
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(PRINT NAME) (OWNER, AGENT, BUILDER, CONTRACTOR)
being duly sworn, deposes and says: that
(PRINT NAME OWNER)
is the owner in fee of the premises to which this application applies; that he/she (the applicant) is duly authorized to make this application; and that the statements
contained here are true to the best of his/her knowledge and belief, and that the work will be performed in the manner set forth in the application and in the plans and
specifications filed therewith, and in accordance with all applicable laws, ordinances and regulations.
(NOTE: The filing of this application does not constitute a permit to commence construction)
Signature of Applicant/Contractor
Westchester County License#
Applicant Sworn Before Me This
Day of
20
AFFIDAVIT OF OWNERSHIP
NOTARY PUBLIC
BUILDING SHORT FORM 12/18
Unique # & NYS #( Fire Alarm Only)
I ,
Page 2 of 4
BUILDING OWNER CERTIFICATION (If applicable):( To be signed by Owner)
I, , hereby certify that I have full knowledge of the proposed alteration at my property as
described herein and take no exception to such activity.
Signature of Property Owner Date
Print Name & Title.
Note: An authorization letter granting the above signed applicant permission to submit this application can be attached to application , in lieu of completing owner certification.
Owner signature not required if work is being done under a Parent Building Permit.
Applicant must provide Parent Building Permit number :
To: Commissioner of Building Subject: Building Permit Application#
Site Address: SBL:
I, , the permitee, to the fullest extent permitted by law, shall save, keep , indemnify and hold
harmless the City of White Plains and their respective officers, officials, employees, and agents from and against all liability, injury, loss or
damage, cost or expense in law or in equity that may at any time arise directly or indirectly by reason of or in the course of performing the work
pursuant to the Building Permit, which may be occasioned by any act or omission of the permitee, any of the permitee's employees, volunteers
or any subcontractor. The foregoing provisions shall not be construed to cause the permitee to indemnify the City of White Plains from it's sole
negligence.
HOLD HARMLESS ( If applicable)
Homeowner to complete only if you will do all the work yourself. ( No employees or subcontractors used.)
Signature:
Date:
Signature:
Applicant /Permitee Name:
Date:
Witness Name:
PERMIT REQUIREMENT AGREEMENT:
I have read, initialed and fully understand the above requirements _______________________________ . Dated: ___________.
(SIGNATURE)
I , _______________________________ , understand and will comply with the following: (Initial each requirement and sign )
(Print Name)
1. Construction shall not begin until the appropriate permit is issued_____.
2. Construction, alterations or repair work shall not start before 7:00am or continue past 7:00pm on weekdays _____.
3. Construction, alterations or repairs shall not start before 9:00am or continue past 7:00pm on weekends _____.
4. Required erosion and sediment control methods will be installed and inspected prior to start of construction _____.
5. Contractor is responsible to call the W.P.Building Dept for all mandatory inspections_____.
6. Revision to work involving structure or life safety systems shall have approved amended plans prior to doing the work______.
