Fillable Plumbing Permit Application 2020 Fillable (Incorporated Village of Northport, NY)

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Plumbing Permit Application 2020 Fillable (Incorporated Village of Northport, NY)

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U.S.A. forms for Incorporated Village of Northport, NY

BROWSE INCORPORATED VILLAGE OF NORTHPORT, NY (NY) FORMS

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PLUMBING PERMIT APPLICATION REQUIREMENTS
INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED
MANDATORY SUBMISSIONS FOR ACCEPTANCE:
*OWNER SIGNATURE on application
*OWNER TAX BILL
*PLUMBER NOTARIZED SIGNATURE
*ESTIMATED COST OF WORK
NO BLANK CHECKS WILL BE ACCEPTED – PAY UPON ISSUE OF PERMIT
*Riser diagram – for rough plumbing DRAWN BY PLUMBER
*Gas schematic – for all gas work DRAWN BY PLUMBER
*LOAD LETTER for new & existing work with proposed meter size
*MFR. SPECIFICATIONS of CHIMNEY LINER for GAS CONVERSIONS
*MFR. SPECIFICATIONS for ALL GAS-FIRED APPLIANCES
*PLUMBER’S LICENSE (FROM town of Huntington only)
*PLUMBER’S INSURANCE CERTIFICATES:
Proof of Liability $2M/1M
Proof of Workmen’s Comp/Disability on NYS Worker’s Comp Board form
Or State Fund (naming Village of Northport as certificate holder)
*ELECTRICIAN’S LICENSE (Suffolk County only) OR
PLUMBER’S LIMITED ELECTRICAL LICENSE
*ELECTRICIAN’S INSURANCE CERTIFICATES:
Proof of Liability $2M/1M
Proof of Workmen’s Comp/Disability on NYS Worker’s Comp Board form
Or State Fund (naming Village of Northport as certificate holder)
*PERMIT EXPIRES AFTER ONE (1) YEAR.
Department of Buildings, Housing, and Code Enforcement
Contractors’ Insurance Information
THE FOLLOWING FORMS ARE REQUIRED FOR LIABILITY, WORKERS'
COMPENSATION, AND DISABILITY INSURANCE
1. LIABILITY INSURANCE WILL BE ACCEPTED ON THE ACORD FORM
2. WORKERS' COMPENSATION INSURANCE
Accepted on one of the following forms only*
Form C-105.2-Certificate of NY State Workers' Compensation Insurance Coverage
Form
GSI-105.2 (2/02) Certificate of Participation in Workers' Compensation Group Board approved
self-insurance
Form U-26.3-NY State Insurance Fund Certificate of Workers Compensation Insurance
3. DISABILITY INSURANCE
Accepted on the following form only*
Form DB-120.1-Certificate of Insurance Under the New York State Disability Benefits
Form DB-155 - Board-approved self-insured employers must obtain this form from Board's
Self-Insurance Office
Certificate Holder:
Inc. Village of Northport
224 Main Street
Northport, NY 11768
EXEMPTION FORM — NEW FORM CE-200 For each and every new
or renewed permit a
signed and dated form with a certificate number must be submitted.
Note: Form CE-200 Is an affidavit for New York Entities with No Employees and Certain Out of State Entities, That New York State
Workers' Compensation and/or Disability Benefits Insurance Coverage Is Not Required
Any questions can be directed to:
New York State Workers Compensation Board
220 Rabro Drive Suite 100
Hauppauge, New York 11788
866-681-5354
Website: www.wcb.ny.gov
CERTIFICATIONS ARE ONLY ACCEPTED ON INDIVIDUAL FORMS
*With valid expiration dates
Department of Buildings, Housing, and Code Enforcement
INC. VILLAGE OF NORTHPORT
PLUMBING PERMIT APPLICATION
__________________________________________ Application #_____________________
Name of Owner (Please Print)
Received Approved____________
______________________________________________________________
Address of Premises
______________________________________________________________
Owners Phone Number
Section_________________Block_______________Lot_______________
Fee __________________________
_____________________________________________________________
C of C ________________________
Address of Owner (if different)
Total _________________________
Residence_________Business________New ________Alteration_________
__________________________________ ________________________
Name of Plumber License Number
ESTIMATED COST OF WORK
__________________________________ _________________________
Plumbers Phone Number $______________________________
ROUGH OUT PLUMBING GAS WORK
Total Number of Plumbing Fixtures:________________
Total Number of Gas Fixtures:_____________________ Sworn to me this ______day of 20_____
I, ________________________________, a plumber,
operating under license # _________________________
of ____________________________hereby acknowledge
that it is unlawful to use solder with content in excess of
two-tenths of one percent (0.20%) on joints in the potable
water supply., and I hereby declare that I will perform in
accordance with that requirement.
___________________________________ __________________________________
Plumber Signature Owners Signature
*ALL PERMITS EXPIRE ONE YEAR FROM DATE OF ISSUE*
I N C O R P O R A T E D 1 8 9 4
224 MAIN STREET
P.O. BOX 358
NORTHPORT, NEW YORK 11768
631-261-7502
ATTENTION: WATER TEST IS REQUIRED ON ALL NEW WASTE PIPING INSTALLATIONS!
MERCURY TEST OR PRESSURE TEST IS REQUIRED ON ALL GAS AND
PROPANE INSTALLATIONS!
******************************************************************************************
1. APPLICATION: completely filled out including name of owner, address of
premises, nearest cross street address of owner if different, plumber license number, address & phone
number.
- indicate the BUILDING PERMIT #, if applicable, in space provided.
- indicate in the boxes provided the fixtures being installed. Be sure that every item of plumbing work is
included to avoid needing to amend the permit later.
- mfr. specifications for chimney liner for gas conversions.
- mfr. specifications for all gas fired appliances
- copy of
- Proof of liability insurance $2.m/1.M
- , including meter bar.
- GAS INSTALLATIONS - indicate what appliances are being installed and include tees being installed for
future connections.
- Application is to be signed at the bottom by a Town Huntington licensed plumber, include License #, and
notarized. If the plumbing work is existing, or done by the resident homeowner the homeowner must sign and
have notarized.
NOTE: Gas Installation is to be done (and signed for) by a Huntington Licensed Plumber only!
2. RISER DIAGRAM is to be provided noting pipe diameters & material.
FOR GAS - supply diagram noting location & size of piping to the meter.
3. FEES
$30.00 for the first two plumbing fixtures or drainage work
$10.00 for each additional fixture
Water Closet (Toilet) Bar Sink Backflow Device
Bidet Laundry Tub Roof Drain
Urinal Slop Sink Main Water Service
Lavatory (Sink) Floor Drain Cesspool Connection
Bathtub Indirect Waste Hot Water Boiler
Shower Drinking Fountain
Kitchen Sink Vent Stack (Other)
GAS: $50.00 for the first two (2) appliances or tanks (includes a Test)
$10.00 for each additional appliance or tank
$50.00 Fee for a reinspection visit or a failed Test.
$10.00 for each future tee connection. (No charge for the first Test at the
time of the future connection) one future only - no future on boilers
OTHER
Fire Suppression: $25.00
Fire Sprinkler: $ .50 per head, Min. $50.00 Commercial
Min. $25.00 Residential
Plumbing Permit # will be assigned after completion of the above. A copy of the Plumbing Permit is provided
the plumber (or Homeowner, if applicable. No work is to start until Permit is issued.
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
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Plumbing Permit Application 2020 Fillable (Incorporated Village of Northport, NY)

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Completed 14 July 2020

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