Fillable Owner-occupant-electrical-permit-application - Owner-Occupant Electrical Permit

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Owner-occupant-electrical-permit-application - Owner-Occupant Electrical Permit

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ELECTRICAL LICENSE BOARD
PO BOX 768 22 GRAND ST
NEWBURGH, NEW YORK 12550
TELEPHONE: (845) 569-7415
OWNER-OCCUPANT ELECTRICAL APPLICATION FOR PERMIT
I hereby apply for an electrical permit to do electrical work in the City of
Newburgh at the following property where I am the owner-occupant and the
building contains not more than two dwelling units.
PREMESIS: ___________________________________________________________________
NAME OF APPLICANT: ________________________________________________________
ADDRESS: ___________________________________________________________________
TELEPHONE NUMBER: ________________________________________________________
ELECTRICAL WORK TO BE DONE AT THIS ADDRESS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
I understand that all electrical work performed must comply with the National Electrical Code
NFPA #70, the City of Newburgh Code of Ordinances, and that I must contact the Inspection
Agency and have an inspection(s) performed by them to receive a certificate that the work meets
the code. If the work does not pass the inspection that I must make the necessary corrections to
do so.
APPROVED INSPECTION AGENCIES ARE ATTACHED. YOU
MUST CHOOSE AN INSPECTION AGENCY PRIOR TO
OBTAINING YOUR PERMIT.
A fee of fifteen dollars ($15.00) in a check payable to the CITY OF NEWBURGH must
accompany this application. Please bring in your certificate of occupancy, tax bill, or proof of
ownership.
DATE: ________________________ SIGNATURE: _____________________________
APPROVAL TO ISSUE PERMIT: _________________________________________________
Fire Chief
Approved Inspection Agencies
Please Select One of The Following
Commonwealth Electrical Inspection Service 845-541-1871
Electrical Underwriters of New York 845-569-1759
Middle Department Inspection Agency 518-273-0861/518-985-2594
New York Board 845-298-6792
New York Certified Electrical Inspectors 845-294-7695
Northeast Electrical Inspections 518-852-0826
NY Electrical Inspections & Consulting 845-343-6934
Swanson Consulting 845-496-4443
Tri-State Inspection Agency 845-986-6514
Z-3 Consultants 845-471-9370
PROCEDURE FOR OWNER-OCCUPANT ELECTRICAL PERMIT APPLICATION
You must be the owner and occupant of a single or two family dwelling to qualify for this
permit:
Please submit the following with your properly completed application:
1. Deed, Certificate of Occupancy, tax bill, or other proof of ownership.
2. A check in the amount of fifteen dollars ($15.00) made payable to the City of
Newburgh.
Your application will be reviewed and approved or denied accordingly.
You will be contacted to either pick up your permit or will be advised as to the reason for denial
and what corrections to make before resubmission.
An electrical inspection must be performed by the inspecting agency designated on the permit
application to ensure the work meets code. In the event the work does not pass the inspection, the
inspector will advise you of the corrections necessary to pass the inspection. The work MUST
pass inspection before the electrical permit can be closed.
Affidavit of Exemption to Show Specific Proof of Workers’ Compensation
Insurance Coverage for a 1, 2, 3, or 4 Family, Owner-occupied Residence
** This for cannot be used to waive the workers’ compensation rights or obligations of any party. **
Under penalty of perjury, I certify that I am the owner of the 1, 2, 3, or 4 family, owner –
occupied 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 (please check the appropriate box):
I am performing all the work for which the building permit was issued.
I am not 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.
I have a homeowner’s insurance policy that is currently in effect and covers the
property listed on the attached building permit AND am hiring or paying
individuals a total of less than 40 hours per week (aggregate hours for all paid
individuals on the jobsite) for work 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’ Compensation 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 jobsite) for work
indicated on the building permit, or if appropriate, file a WC/DB-100 exemption form; OR
Have the general contractor, performing the work on the 1, 2, 3, or 4 family, owner-occupied
residence (including condominiums) listed on the building permit that I am applying for, provide
appropriate proof of workers’ compensation coverage or proof of exemption from that coverage
on forms approved by the Chair of the NYS Workers’ Compensation 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 jobsite) for work indicated on the
building permit.
_________________________________ ________________________
Signature of Homeowner Date Signed
_________________________________ ________________________
Homeowner Name Printed Telephone Number
Property Address that requires the building
permit:
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
Once notarized, this Form BP-1 serves as an exemption for both workers’ compensation
and disability benefits insurance coverage.
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Completed 12 July 2020

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