APPLICATION FOR DEMOLITION PERMIT
Issued Pursuant to the Provisions of the Code of the VILLAGE OF NORTHPORT
FEE $ __________ Phone: 631-261-7502 Permit No. ____________________
C.O. $ __________ FAX: 261-7521 Approved ______________, 20___
C.C. $ __________ ______________________________
Director
AGE OF STRUCTURE: _________. NOTE: IF STRUCTURE IS 100 YRS. OR OLDER,
COMPLETE ATTACHED HISTORIC REVIEW APPLICATION.
SCTM # 0404 Zone ________ Section ________ Block ________ Lot(s) ________
Location ____________________________________________________________________________
Estimated Cost ________________________
Size of structure(s) to be demolished: Height _______________ Square Footage __________________
Method of demolition (EXPLAIN BRIEFLY) __________________________________________________
How will you dispose of debris? __________________________________________________________
____________________________________________________________________________________
If excavation results, how do you intend to fill? ______________________________________________
When do you expect to start operations? __________________________________________________
CARTING TAGS MUST BE SUBMITTED STATING DISPOSITION OF DEBRIS
For utility notifications dial 811 or TOLL FREE 1-800-272-4480
CALL BEFORE YOU DIG --- IT’S THE LAW
NYS Industrial Code Rule 53 Mandates 2-10 business days notice prior to excavation
NOTES:
1. The New York State Building Construction Code and the Code of the Village of Northport
Requirements are imposed as a condition on issuing a Permit.
2. FOR ALL BUILDING AND DEMOLITION PERMITS: The Code of the Village of Northport can be found online
At: http://www.ecode360.com/?custid=NO0083
3. A valid Permit will only be issued subject to the provisions of §57 of the Worker’s Compensation Law and §220-8 of the Disability
Benefits Law.
4. The owner shall indemnify and hold the municipality harmless and defend against any claim of liability or loss including the cost of
defense for personal injury or property damage resulting from or arising directly or indirectly out of or resulting from the permit
holders operations within the municipality, including losses arising out of the negligent acts or omissions of the contractor, its servants
or agents, and any subcontractors, its servants or agents
AFFIDAVIT OF PROPERTY OWNER
STATE OF NEW YORK}
SS:
COUNTY OF SUFFOLK}
__________________________________________________________________being duly sworn,
Deposes and says: That he resides at ____________________ in the ___________________________
Street Town or City
In the State of __________________________, that he is owner in fee of all that certain lot, piece or
Parcel of land shown on the attached survey situate, lying and being within the Incorporated Village of
Northport; that the work proposed to be done upon the said premises, will be done in accordance
with the approved application and accompanying plans.
That _______________________________________________________________________________
Name of Applicant (please print)
Is duly authorized by the aforesaid ________________________ 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.
Sworn to before me this ____________ day Owner ________________________________
Signature
Of ________________________, 20 _____ Applicant ________________________________
Signature
___________________________________ Address _________________________________
Notary Public
Phone _________________________________
