yes- no- TOWN OF SHAWANGLINK BUILDING DEPARTMENT PO BOX CENTRAL AVENUE WALLKILL, NY PHONE L62 FAX

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1 TOWN OF SHAWANGLINK BUILDING DEPARTMENT PO BOX CENTRAL AVENUE WALLKILL, NY PHONE L62 FAX APPLICATION FORA BUILDING PERMIT PERMIT #: DATE: DISTRICT: (TO BE COMPLETED BY BTIILDING DEPT.) PLEASE NOTE THE BUILDING DEPARTMENT WILL NOT ACCEPT INCOMPLETE APPLICATIONS. THE GRAPH PAPER PROVIDED MUST BE FILLED IN. IT IS APPLICANTS RESPONSIBILITY TO MAKE SURE ALL-APPLICABLE INSPECTIONS ARE COMPLETED INCLIIDING THE FINAL INSPECTION. BUILDING PERMIT REMAINS VALID FOR ONE (1) YEAR FROM DATE OF ISSUANCE. PERMIT MAY BE RENEWED ANNUALLY PROPERTY OWNERS NAME: PHONE #: MAILING ADDRESS PROPERTY LOCATION OF' CONSTRUCTION: DIRECTIONS TO PROPERTY: LOT SIZE: SECTTON, BLOCK& LOT# This application for a building permit is made to the Town of Shawangunk building inspector. Please cornplete this form and include any other information that may be pertinent to this application. Signature of Applicant: certifies that he/she is the owner or agent of all said parcel, lot or piece of land or building described in this application and if not the owner that he or she has been duly authorized to submit this application and to assume the responsibility for the owner for this application. This owner or agent agrees to comply with the Town of Shawangunk Zoning ordinance as well as all New York STATE and local codes and regulations relating to the conskuction and use of the proposed building and lands on this application. GENERAL CONTRACTOR'S NAME: GENERAL CONTRACTORS ADDRESS: PHONE #: CELL #: INSURANCE CARRIER: PHONE: Do you currently have an application before the Planning Board or ZBA? yes- no- If yes please explain:

2 T APPLIES TO CONSTRUCTION BUILDING SPECIFICATIONS TYPE OF CONSTRUCTION: OCCUPANCY OFDWELLING: FOUNDATIONTYPE: % OF BASEMENT FINISHED:- HEAT TYPE: FUEL: STORIES TOTAL NUMBER OF ROOMS: BEDROOMS: BATHS:-=--- FAMILY ROOMS: GREATROOMS: LIVINGROOMS: BONUS ROOMS: NUMBER OF FIREPLACES: FIREPLACE INSERTS: WOODSTOVES: MANUFACTURER: TYPE OF GARAGE NTIMBER OF CARS: STORIES SIZE OF GARAGE: CARPORT: DECK SIZE: COVERED PORCH: PATIO: ENCLOSED PORCH: ACCESSORY BLDG. SIZE: ABOVE GROUND POOL SIZE: ACCESSORY BLDG. USE: INGROUND POOL SIZE: DECK SIZE IF ATTACHED: TOTAL SQ. FT. OF LTVING AREA: ---sq. FT. OF ADDITIONAL CONSTRUCTION SIDING TYPE; COST OF CONSTRUCTION: PLEASE STATE SPECIFICALLY WHAT TIIIS APPLICATION IS FOR: F'EE: ** ON TIIE PROVIDED GRAPH PAPER, DRAW FOOTPRTNT (EXTERIOR DIMENSIONS) OF PROPOSED CONSTRUCTION, SHOWING DISTANCES FROM ALL PROPERTY LINES AND DISTANCES FROM ANY STRUCTURES. **

3 Affidavit of Bxemption to Show Specilic Proof of Workers' Compensation Insurance Coverage for a 1,2,3 or 4 Family, Owner-occupied Residence **This form canuol be asetl to waive the worhen' utmpensution rights or ohligations of any party.** Under penalty of perjury, I certify fhat Iam thc owncrof the l,2,3 or4 farnily, own r-occupied resiclence (including condominiums) listed on the building permit that I am applying tbr, and I am not required to show specific proof of workers' sompensation insurance coverage for such residence because (please check the appropriate box): f, I anr perlbrming all the work Ibr which the burlclirrg pernrit was issued. n n I am not hiring, paying or compcnsating in any way, the individual(s) that is(are) performing all the work for which the building permit was issucd or helping me perfurm such work. I have a homeowner's insurance policy that is currently in cffect ancl coverc the properfy listed on the attached building permit AND am hiring or paying individuals a total of less than 40 hours per week (aggregatc hours for all paid individuals on thc.iobsite) ft-rr which thc building permit was issued. I also agree to either: I acquire apprr:priate workers'compensation covcrage and provide appropriate proot'of that coverage on fornrs 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 of40 hours or more per weck (aggregate hours for all paid individuals on the iobsite) tbr work indicated on the building permit, or if apprcrpriate. file a WC/DB-100 exemption form; OR t have the general contractor, performing the work on the l, 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 ltom that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entify issuing the building permit if the project takes a total of 40 hours ormorc per week (aggregate hours for all paid individuals on the jobsite) for work indicated on the building permit. (Si gnature of Homeowner) (Homeowner's Name Printed) (Date Signed) Homc Telephone Number sworn to be/orc mc thls day of Property Address that requires the building permit: pnce notarizcd, this Form lnsurunce coverage. BP-l serves as an ex mpfion for both workers' compensation and disability benefits BP-l (9-07) IIY-WCB

4 I-AWS OI.'NEW YORK. I998 CIIAPTER 439 The general municipal law is nmended b1'adding a new section 125 to read as fbllows: ISSUANCE OF Rt.,lLDIN(i PF.RMIT'S. N0 (ll'ry.'k)wn (Xl vlt,l,nclr SllAl.l- ISSLiU A IIUIL.DIN(; I'I:RMII' WITHOUT OBTA ININC FROM'TH E PE R M TI- APPI.ICAN'I' F;ITFI ER : I. PROOF DULY SUBSCRII}ED]'HAT WORKNRS' COMPENSATI0N INSURANCU AND DISAT}ILII'Y I]F,NEFITS COVERAGE ISSIIED BY AN INSURANCE CIARRIER IN A FORM SATISFACTORY TO TltE CI'IAIR OF 1'I{I1 WORKERS' COMPENSATION BOARD AS PROVIDED F'OR IN SEC:I'ION I.IT*TY.SEVF]N OF THE WORKERS' COMPENSATION LAW ls F.FFECTIVE; OR 2. AN AFFIDAVIT THAT SUC]II PERMIT APPLICANT }IAS NOT I]NGACED AN EMPLOYNR OIT ANY EMPLOYEES AS THOSE TEITMS ARE DBIIINTD IN SE(INON TWO of'tt{e WORKI.,RS" COMPENSATION I,AW TO PERFORM WORK RELATINC'rO SUCI'I BIIILDING PIIRMII'. Implementing Section 125 of the General Municipal Law 1. General Contractors - Busine.ss Owners and Certain Homeowners For businesses and certain homeowaers listed as the general contractors on building permits, proof that they are in compliance with Section 57 of thc Workers'Clompcrr-sation l.aw (WCl,) is ONE olthe lirllowing tbrms that indicate that they are: I insured (C or U-26.3), r a Board-approved seltinsured employer (SI- l2). or are exempt (WC/DB-,l00), t under the mandatory coverage provisions of the WCl.. Any residence that is nu a l, 2,3 or 4 tr'amily, Owner-occupied Residence is considered a business (income or potential income prope*y) and must prove compliance by filing one of thc above forrns. 2. Owner-occupied Residences For homeowners of * 1r2,3 or 4 Family, Qggg;ggggplg! Residencq proof of their exemption from the mandatory coverage provisions of the Workers' Compensation l.aw when applying for a building pemrit is to file Fomr BP- l. o Form BP-l shall be filed if the homeownerof a 1,2,3 or 4 Resideoce is listed as the geneml contractor on the building permit, and the homcowner: 0 is performing atl the work lbr which the building permit was issued him/herself, 0 is nor hiring, paying or compensating in any way, the individual(s) that is(are) pcrforming all the work for which thc building permit was issucd or hclping the homeowner perform such work, or 0 has a homeeiwner's insurance policy that is currently in effect and covers the property for which the building permit was issued AND the homeowner is hiring or paying individuals a total of less than 40 bours per week (aggregate hours lbr all paid individuals on the jobsite) for tlre work for which thc building permit rvas iszued. r lf the homeowner of a l, 2,3 or 4 Family, fulglggg4lgd Residence is hiring or paying intlividuals a total of 40 bours or MORE in aoy week (aggrcgatc hours firr all paid individuals on the jobsitc) for thc work for which the building permit was issued, then the homeowner may not file tle "Affrdavit of Exemprion" Fomr RP- I, hut shall either: 0 acquire appropriate workers' compensatioil coverage and provide appropriate proofofthat coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the govemment entity issuilg the building permit (Form C-I05.2 or Form U-26.3), OR 0 have the geoeral contractor, performing the work on the l, 2, 3 or 4 family, owner-occupied residence (including condominiums) listed on the building permit, provide appropriate proofofrvorkers" compensation coverage, or proof of exemption from that coverage on forrns approvcd by the Chair of the NYS Wnrkers' Compensation [loard to the gnvernment entiry issuing the building penrrit. BP-l (9-07) Reverse

5 t- a On this graph paper you must draw a foot print proposed construction as well as all existing a f.orn th" pt A drawing of the proposed construction must paper

6 TOWN OF S}IAV/ANGLINK BUILDING FIELD REPORT NAME PHONE ADDRESS SECTION, BLOCK & LOT NUMBER LOCATION AND DIRECTIONS * * * ***,I * *FOLLOWING TO BE COMPLETED BY BUILDING INSPECTOR* *'T * * * * * * PERMIT REQUESTED FOR ZONING DISTzuCT LOT SIZE LOT SIZE MEETS ZONING REQUIREMENT: YES NO FRONT, SIDE, REAR SETBACKS MEET REQUIREMENT: YES DRIVEWAYPERMITREQUIRED: YES-NO NO STATE HIGIIWAY COUNTY TOWN FLOCD ZONE: \aes NO MAP # WETLAND DESIGNATION MAP # CRITICAL ENVIRONMENTAL AREA: YES NO RECREATIONALRIVERCORzuDOR; YES NO RIDGE_, =-AQUIFER- PERMIT ISSTIED: YES NO DATE REASON FORDENIAL: INSPECTOR'S COMMENTS: DATE GEORGE SAWYER CODE ENFORCEMENT/ZONING OFFICER