INSTRUCTIONS/ CHECK LIST. Please Note: Completing the application form does not constitute a permit to commence construction.

Transcription

1 INSTRUCTIONS/ CHECK LIST Please Note: Completing the application form does not constitute a permit to commence construction. To complete the application process, you will need to deliver to the building department the following: A signed/ notarized application form If applicable, architectural plans, stamped and signed by a NYS licensed Architect or Professional Engineer in the following formats: o Full size set o 11x17 set o Electronic set (.pdf) Contractor s Certificate of Liability listing the City of New Rochelle as the Certificate Holder and Additional Insured. Certificate of Disability Insurance. Contractor s Workman s Compensation or a Waiver of Insurance if all work to be performed by the property owner. Westchester County Home Improvement License. Note: Please be advised, under new State and Municipal Laws, the Workman s Compensation and disability benefits insurance must be submitted on separate state approved forms. The Acord Form are no longer acceptable proof of Workman s Compensation coverage. Further information or questions may be answered by calling the NYS Bureau of Compliance at (518) or by visiting their website: or by contacting the insurance provider.

2 APPLICATION FOR BUILDING PERMIT THE CITY OF NEW ROCHELLE 515 North Ave New Rochelle, NY Location Application No. Date Job Location Block-Lot Unit No /2/ :21:21 AM 123 Calton Rd Zoning Property Class Property Owner Occupancy R1-10A 1 Family Res JANELLE HINTON One/ Two Family Applicant Contact Person Name of Business Phone Number Kaja Gam Design Inc info@kajagamdesign.com dba KG Home Contractor Contact Person Name of Business Phone Number Kaja Gam Design Inc info@kajagamdesign.com dba KG Home License Name License Number Expiration Project Description Type of Application Applicant is Work Requested By In Association W/ Interior Renovation/ Repair Building sprinkled...? DESCRIPTION OF WORK Contractor The Owner $70,000 Smoke detectors...spaces? RENOVATE KITCHEN AND 1 BATH AND PAINT. Dumpster in driveway Estimated Cost Impervious surface? Plumbing work? Electrical work? No Yes No Yes Yes Date filed: Fee paid: Reciept No.: Initials:

3 AFFIDAVIT OF APPLICANT I: Kaja Gam Design Inc being duly sworn, depose and says: That s/he does business as: dba KG Home with offices at: 127 Main Street, 2ND FLOOR and that s/he is: The owner of the premises described herein. The of the New York Corporation with offices at: duly authorized by resolution of the Board of Directors, and that said Corporation is duly authorized by the Owner to make this application. A General Partner of with offices at and that said Partnership is duly authorized by Owner to make this application. The Lessee of the premises, duly authorized by the owner to make this application. The Architect or Engineer duly authorized by the owner to make this application. The contractor authorized by the owner to make this application. Sworn to before me this day of of Notary Public/ Comm. of Deeds Applicant's Signature AFFIDAVIT OF OWNER (do not complete if owner is applicant above) I: JANELLE HINTON being duly sworn, depose and says: That s/he does business as: with offices at : and that s/he is: The owner of the premises described herein. The of the New York Corporation with offices at: duly authorized by resolution of the Board of Directors, and that said Corporation is duly authorized by the Owner to make this application. A General Partner of with offices at and that said Partnership is duly authorized by Owner to make this application. That the applicant : Kaja Gam Design Inc is duly authorized to apply for the permit as described in this application and drawings. The undersigned hereby agrees to comply with all the requirements of the New York State Uniform Fire Prevention and Building Code, the New Rochelle Building Code, Zoning Ordinance and all other laws pertaining to same, in the construction applied for, Sworn to before me this day of 20 Notary Public/ Comm. of Deeds Owner's Signature

4 AFFIDAVIT OF DESIGNER I: being duly sworn, depose and says: That s/he does business as: with offices at: and that s/he and that s/he personally supervised the: preparation of the architectural, structural, mechanical plans and that to the best of his/her knowledge and belief, the work applied for, if performed in accordance with such plans will with all the provisions of the New York State Uniform Fire Prevention and Building Code, the New Rochelle Building Code, Zoning Ordinance and with the provisions of all other laws and regulations applicable thereto in effect this date. Deponent further states that s/he prepared or personally supervised the preparation of the plans, specifications and energy conversation study and that to the best of his/her knowledge and belief, if constructed in accordance with such plans and specifications the structure will conform with all applicable provisions of the New York State Energy Conversation Code and the specific requirements of the City of New Rochelle, New York, of 5750 degree days. Deponent further says that s/he is duly authorized by JANELLE HINTON who is the owner in fee of all that certain lot, piece or parcel of land described on this application, to make application for approval of such plans and specifications on the Owner s behalf. Designer Professional Seal Architect's Signature (Not be applicable if design professional is architect) I: being duly sworn, depose and says: That s/he does business as: with offices at: and that s/he and that s/he personally supervised the: preparation of the architectural, structural, mechanical plans and that to the best of his/her knowledge and belief, the work applied for, if performed in accordance with such plans will with all the provisions of the New York State Uniform Fire Prevention and Building Code, the New Rochelle Building Code, Zoning Ordinance and with the provisions of all other laws and regulations applicable thereto in effect this date. Deponent further states that s/he prepared or personally supervised the preparation of the plans, specifications and energy conversation study and that to the best of his/her knowledge and belief, if constructed in accordance with such plans and specifications the structure will conform with all applicable provisions of the New York State Energy Conversation Code and the specific requirements of the City of New Rochelle, New York, of 5750 degree days. Deponent further says that s/he is duly authorized by JANELLE HINTON who is the owner in fee of all that certain lot, piece or parcel of land described on this application, to make application for approval of such plans and specifications on the Owner s behalf. Designer Professional Seal Engineer's Signature

5 AFFIDAVIT OF CONTRACTOR I: Kaja Gam Design Inc being duly sworn, depose and says: That s/he does business as: dba KG Home with offices at: 127 Main Street, 2ND FLOOR and: S/he of the afforemention New York Corporation. The provisions of the Workman s Compensation Law do not apply to him in that all work to be performed under this application will be performed by him and that no laborer is or will be at anytime employed by him at the subject location in the, NY. (Submit Workman s Compensation approval). The undersigned further states: That the work will be performed in accordance with the New York State Uniform Fire Prevention and Building Code, of the New Rochelle Building Code, the New Rochelle Zoning Ordinance and all other applicable codes and regulations whether or not shown on the plans and specifications in the subject application, and he assumes responsibility for all acts and work performed by sub-contractors, Laborers, and Material-men in connection with the work performed. Sworn to before me this day of 20 Notary Public/ Com. of Deeds Contractor's Signature OWNER'S AUTHORIZATION I: JANELLE HINTON as the owner of the subject premises and have authorized the contractor named above to perform the work under the subject application. Sworn to before me this day of 20 Notary Public/ Com. of Deeds Owner's Signature Note: 1. State Law requires that the contractor submit a copy of Workman s Compensation as required by the New York State Disability Insurance naming the Bureau of Buildings, City of New Rochelle as a certificate holder and showing coverage for general contracting and the locations covered by such insurance. If a structure is to be demolished, a copy of Liability Insurance must also be submitted. 2. The filing of this permit application does not constitute a permit to commence construction.