Minimum of two weeks processing time- (14 business days)

Transcription

1 TOWN OF MARBLETOWN NAME: SBL BUILDING & SAFETY DEPARTMENT 3775 Main Street! P.O. Box 217 ZP# Stone Ridge, NY x 3 DEM~O~P~E=RM~I=T~ building@marbletown.net APPLICATION FOR A DEMO PERMIT Fill out complete application, please print clearly and attach the following: Attach a copy ofyour deed. Affix a clear photo of what is being demolished Attach your insurance information Application must include waiver OR contractors insurance Applications without proper insurance forms will not be accepted INSURANCE INFORMATION -MUST ATTACH INSURANCE FORM contractors proof of Liability (Acord form) and Workers' Compensation (CI05.2 or U26,3) or Homeowners' Exempt form Ifyou are listing a contractor, Liability and Workers' Comp or Liability and Workers Comp Exempt forms must be attached to this permit application, if no contractor BP-t Homeowners exempt form to be submitted with your application. (fyour contractor is exempt they must submit exemption form: Workers' Comp Exempt form can be filled out electronicaljy and printed on the Board's website Any questions can be answered by calling the NYS Workers' ComP Board If you are not listing a contractor and you are doing the work yourself, (enclosed is the Bp t homeowners exempt form, fill it out, sign, notarize it and attach it to this permit application) Only a complete packet and original copy (not faxed or ed) ofthe application will be accepted for processing with ALL documents submitted - our office cannot accept an incomplete packet Once a complete packet is received we will start the process Minimum of two weeks processing time- (14 business days) Received:

2 Town of Marbletown Building & Safety Office p.o. Box Main Street Stone Ridge NY Office use SBL ext. 3 building@marbletown.net ZP DEMO PERMIT Application for a Demolition Permit Print clearly and complete all information Ifincomplete. permit will not be processed until information is obtained Owner Mailing Address: City/State Zip Code Phone number: AddresslLocation of site: Section Block & Lot #,Zoning Dist. # of Acres Brief explanation of what you are removing: Affix a clear photo of structure to be removed in this box (application can not be accepted without photo) Are you hiring a contractor? ---yes (attach insurance forms) no (attach waiver) Contractor Name: Mailing address: City/State...;Zip Code: Phone number: Cell number: attached proqj' Qj'ins uranee: Liability Workmens' Compo Workmens' Comp Exempt MUST ATTACH INSURANCE FORMS""" APPLICATIONS CANNOT BE ACCEPTED WITHOUT THEM

3 Town of Marbletown Building & Safety Office P.O. Box 217 I 3775 Main Street Stone Ridge, NY ext. 3 E mail: buijding@marbletown.net A list of inspections will be attached to the required on site building plans which will be included with your permit. Dig Safely Master Member list By law, Excavators must call Dig Safely. New York at www,digsafelynewyork,com at least 2 full working days before to request a stake-out of underground utility lines. As of March 16,1996 the following organizations own buried facilities in the Town of Marbletown and are members ofthe Dig Safely, New York "one-call" notification system, Note: This list does not contain members in any villages or cities that may exist in this town. One free phone call to Dig Safely, New York contacts: Organizations; CENTRAL HUDSON GAS & ELECTRIC, NY TELEPHONE C/O BYERS ENGINEERING, ROLLING MEADOWS WATER CORP. [(we) understand that it is a violation of the Town of Marbletown Zoning Law to use/occupy without first obtaining a Certificate of Occupancy/Compliance from the Codes Enforcement Officer. A MAXIMUM $250.00/WEEK AND OR IMPRISONMENT. I(we) the undersigned, understand that any incomplete or omitted information on plans and (or) description of work as submitted to the building department for the issuing of a building permit shall be constructed/installed in compliance with all applicable rules, regulations and codes in effect at the time of this signing. I hereby grant the building inspector or his or her authorized agent permission to enter upon the premises and into nay building or building structure thereon at anytime during working hours without being subject to arrest or civil suit for trespassing. I(we) understand that if a permit is issued they are good for one year of date of issuance and a fee of $25.00 or 10% ofthe original permit fee (whichever is higher) will be applied to renewal or expired permits each year thereafter if applicable, THE BUILDING INSPECTOR OR HIS OR HER AUTHORIZED AGENT IS HEREBY GRANTED PERMISSION TO ENTER UPON THE PREMISES AND INTO ANY BUILDING OR STRUCTURE THEREON AT ANYTIME DURING WORKING HOURS WITHOUT BEING SUBJECT TO ARREST OR CIVIL SUIT FOR TRESPASSING. Signature ofowner Date Signature of ApplicantlBuilder Date If the applicant is not the owner of the premises, a letter of agent from the owner, notarized designating the applicant as their agent is required. Name and phone number to call when permit is ready ~~~~~--~~~-~~~ I_--_ Ifnot filled in permit will be mailed to homeowners mailing address OFFICE USE ONLY Application Copy of Deed Insurance Info. Check (if applicable) Zoning Permit Receipt of disposal ofdemolition: Check No. No Charge for residential demolition $50.00 for commercial demolition Make your check out to the Town of Marbletown Receipt No. Paid: Received:

4 Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance Coverage for a 1,2,3 or 4 Family, Owner-occupied Residence UThJs form cannot be used to waive the workers' compensation rights or obligations ofany pari)!. ** 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): o I am performing all the work for which the building permit was issued. o 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. o I have a homeowners 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 which the building permit was issued. I also agree to either: + acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on fonns approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing. the building permit ifi need to hire or pay individuals atotal of40 hours or more per week (aggregate hours for all paid individuals on the jobsite) for work indicated on the building pennit, or ifappropriate, file ace 200 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 proofof 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 the project takes a total of40 hours or more per week (aggregate hours for all paid individuals on the jobsite) for work indicated on the building permit. (Signature of Homeowner) (Homeowner's Name Printed) Property Address that requires the building permit: (Date Signed) Home Telephone Number 1'n to before mil this day of Once notarized, this BP.l form serves as an exemption for both workers' compensation and disability benefits Insurance coverage. HOMEOWNERS EXEMPT form (BP.1) NY WCB

5 LAWS OF NEW YORK,1998 CHAPTER 439 The general municipal law Is amended by addinl;1 a new section 125 to read as follows: ISSUANCE OF BUILDING PERMITS. NO CITY, TOWN OR VILLAGE SHALL ISSUE ABUILDING PERMIT WITHOUT OBTAINING FROM THE PERMIT APPLICANT EITHER: LPROOF DULY SUBSCRIBED THAT WORKERS' COMPENSATION INSURANCE AND DISABILITY BENEFITS COVERAGE ISSUED BY AN INSURANCE CARRIER IN AFORM SATISFACfORY TO THE CHAIR OF THE WORKERS' COMPENSATION BOARD AS PROVIDED POR IN SECTION FIFTY SEVEN OF THE WORKERS' COMPENSATION LAW IS EFFECTIVE; OR 2. AN AFFIDAVIT THAT SUCH PERMIT APPLICANT HAS NOT ENGAGED AN EMPLOYER OR ANY EMPLOYEES AS THOSE TERMS ARE DEFINED IN SECTION TWO OF THE WORKERS' COMPENSATION LAW TO PERFORM WORK RELATING TO SUCH BUILDING PERMIT. Implementing Section 125 of the General Municipal Law 1. Geleral Contractors -- Business Owners and Certain Homeowners For businesses and certain bomeowners listed as tbe general contractors on building permits, proof that they are in compliance with Section 57 of the Workers' Compensation Law (WCL) is ONE of the following forms that indicate that they are: insured (C-IOS.2 or U 26.3), self-insured (SI-12), or + are exempt(ce-zoo). under the mandatory coverage provisions of the \VCL. Any residence that is not a 1,2,3 or 4 Family,Qwn,r-occupied Residence is considered a business (income or potential income property) and must prove compliance by filing one of the above forms. 2. Owner-occupied Residences For homeowners of a 1, 2, 3 or 4 Family, Owner-occupied Residence, proofof their exemption from the mandatory.coverage provisions of the Workers' Compensation Law when applying for a building pennit is to file form Bp l. + Form BP-lshall be filed ifthe homeowner ofa 1, 2, 30r 4 Family, Owner-occupied Residence is listed as the general contractor on the building pennit, and the homeowner: o is perfonning all the work for which the building permit was issued himlherself, o is not hiring. paying or compensating in any way. the individuaj(s) that is(are) perfonning all the work for which the building pennit was issued or helping the homeowner perfonn such work, or o has a homeowner's insurance policy that is currently in effect and covers the property for which the building pennit was issued AND the homeowner is hiring or paying individuals a total oftess than 40 hours per week (aggregate hours for all paid individuals on the jobsite) for the work for which the building permit was issued. +. lfthe homeowner of a It 2t 3 or 4 RamUy, OW,nU-pccupled Residence is hiring or paying individuals a total of 40 bours or MORE in any week (aggregate hour:s for all paid individuals on the jobsite) for the work for which the building permit was issued, then the homeownermay not file the "Affidavit of Exemption" form, BP l(ll104), but shall ~~. o acquire appropriate workers' compensation coverage and provide appropriate proofofthat coverage onforms approved by the Chair of the NYSWorkers' Compensation Board to the government entity issuing the building permit (the C-10S.2 or U-26.3 fonn), OR o have the general contractor, (performing the work on the I, 2, 3 or 4 family, owner-occupied residence (including condominiums) listed on the building pennit) provide appropriate proofof workers' compensation c\?verage. or proof ofexemption from that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit. BP-l (12/08) Reverse