INC. VILLAGE OF CEDARHURST
BUILDING PERMIT APPLICATION
200 Cedarhurst Ave. Cedarhurst, NY 11516
Office: (516)295-5770 Email: building@cedarhurst.gov Website: cedarhurst.
gov
The owner of this building and the undersigned agree to conform to all applicable laws of the Village of Cedarhurst
AFFIDAVIT OF CONTRACTOR
AFFIDAVIT OF PROPERTY OWNER
STATE of NEW YORK
COUNTY OF NASSAU
(PRINT NAME) being duly sworn,
deposes and says: That he/she resides at
in the State of and that he/she is
authorized by the
Owner to make application for a permit to
perform said work in the foregoing application and accompanying plans, and all the
statement contained therein are true to deponent’s own knowledge.
Address
Phone
Sign Here
Sworn to before me this Day of 20
STATE of NEW YORK
COUNTY OF NASSAU
(PRINT NAME) being duly sworn,
deposes and says: That he/she resides at
in the of
in the State of ,that he/she is the owner in fact of all
that certain lot, piece or parcel of land shown on the diagram above situate, lying
and being within the INCORPORATED VILLAGE OF CEDARHURST, that the work
proposed to be done upon the said premises will be done in accordance with the,
approved application and accompanying plans, (and he/she hereby authorizes
APPLICANT
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.
Sign here
Sworn to before me this Day of 20
(Applicant)
(Owner)
DO NOT WRITE BELOW THIS LINE - FOR DEPARTMENT USE ONLY
Adjusted Cost Permit Fee - 1st Permit Fee - 2nd Total Site Plan Fee
$
$
$
$
Approved by Permit Title
House No. Assigned
FEMA Flood
Hazard Zone
Zone By
Base Flood Elevation
Variance Yes No
If Yes date and case No.
Elevation Certificate: Yes No
Final Survey Required: Yes No
New C.O. Required: Yes No
Separate Application Required For:
HVAC Plumbing Electric
Sign/Awning Other
SIDEWALKS, CURBS AND/OR CURB CUTS
Date
Receipt #
Fee Paid $
Sec. Block
Lot(s)
1. Name of Owner
2. Address
3. Locaon & size of sidewalk, curb and/or curb cut
4. Is this project in conjuncon with a new or altered building?
5. Name of Contractor
6. Address of Contractor
Signature of Applicant Date
No permit issued to any person or persons, rm, associaon or corporaon shall be constructed to relieve any
applicant for such permit of the duty to properly guard any such construcon by guard rails, signal lights or such
other means as may be necessary to warn pedestrians on the sidewalk of the danger to be apprehended from such
construcon, nor shall any permit be construed in any manner to make liable the Village of Cedarhurst for any
negligence if such applicant in making such construcon.
In consideraon of the granng of the permit the applicant shall save and keep harmless the Village of Cedarhurst
from all damages caused by the negligence of such applicant in making such construcon, or in properly guarding
the same, or in causing the said sidewalk and/or curb to be restored to its proper condion
Construcon of sidewalks, curbs and/or curb cuts shall be constructed as per Village Ordinance and specicaons.
PLEASE NOTE
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