BUILDING PLANS ON SITE AFFIDAVIT - Read, sign and include this document in with packet (attached (0 application)

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1 TOWN OF MARBLETOWN BUILDING AND ZONING PERMIT APPLICATION P.O. BOX 217 STONE RIDGE, NY Fax office use only: Name: SBL# DECK I RAMP PERMIT APPLICATION Complete the pennit application and attach the following documents to your building pennit application BLDG PERMIT# ZONING PERMIT DECK I RAMP PERMIT ~D::.!E,,-!E=:.!D~- Copy ofyour filed deed. Must show Liber and page number. BUILDING PLANS ON SITE AFFIDAVIT - Read, sign and include this document in with packet (attached (0 application) SITE PLAN: Showing location ofall Existing structures, well, utilities lines, septic and new structure(s). Include all dimensions from the center ofroad, and from the side and rear property lines and Must show location of well, septic and electric lines and complete # 7 & 8 PLANS: Plans must show cross section ofconstruction Computer generated drawings must submit 2 full sets ofplans and provide drawings on a CD. Hand drawn plans must submit 2 full sets ofplans on letter or legal size paper only. LETTER OF CONSENT: If the Contractor/Applicant is not the owner ofthe premises, a letter ofagent from the owner, notarized designating the applicant as their agent is required (only ifthe homeowner has not signed the application) CHECK: Please bring a check payable to the Town ofmarbletown INSURANCE INFORMATION -attach,contractors proof of Liability and Workers' Compensation 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. Call your insurance company and have them fax/ the certificates directly to you and attach them to your application. Ifyour contractor is exempt they must submit exemption form: Workers' Comp Exempt - form can be filled out electronically and printed on the Board's website - Any questions can be answered by calling the NYS Workers' Como Board Ifyou are not listing a contractor and you are doing the work yourself, enclosed is the BP-I homeowners exempt form, fill it out, sign, notarize it and attach it to this permit application Only a complete packet and original copy (notfaxed 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)

2 Office use only: TOWN OF MARBLETOWN Building permit number 3775 Main Street I P.O. Box 217 Zoning permit number Stone Ridge, NY S.B.L x 3 DECK/RAMP building@marbletown.net Website: PRINT CLEARL Y and COMPLETE ALL INFORMATION Ifnot completed, application will delayed until information is obtained OWNER:,APPLICANT: - MAILING ADDRESS: MAILING ADDRESS: PHONE NUMBER: PHONE NUMBER: CELL NUMBER: CELLNUMBER: WORK NUMBER: WORK NUMBER: , PROPERTYADDRESS: 1. SECTION.BLOCK,,LOT,NUMBER OF ACRES,ZONING DIST. 2. EXISTING USE IOCCUPANCY OF PROPERTY: SINGLE FAMILY RESIDENCE, VACANT LAND, _ OTHER 3. NATURE OF WORK: DEMOLITION, _NEW ADDITION, ALTERATION, REPAIR 4. GIVE A BRIEF DESCRIPTION OF THE WORK YOU ARE DOING: 5. Check all that apply: ( ) FRONT DECK ( ) REAR DECK ( ) SIDE DECK 6. SQUARE FOOTAGE OF DECK: sq. ft. 7 DIMENSIONS OF PROPOSED STRUCTURE: LENGTH WIDTH HEIGHT 8. SETBACKS: FROM CENTER OF ROAD REAR LEFT RIGHT 9. ELECTRIC: ( ) NO ( ) YES must be inspected by a Town approved agency - listed below NY Certified Electrical Inspectors - John Metsger Electrical Underwriters of NY - Ernest Bello TYPE OF USE: ( ) PERSONAL, ( ) BUSINESS, ( ) MIXED OCCUPANCY, SPECIFY EACH TYPE OF USE: 11. HAS THE CONSTRUCTION SITE (OR PORTION THEREOF) BEEN DESIGNATED AS A FLOOD HAZARD OR WETLANDS (AS PER FLOOD INSURANCE RATE MAP OR STATE WETLANDS MAPS ): (N) (Y) 12. PERCENTAGE OF LOT COVERAGE (INCLUDING ALL BUILDINGS) LESS THAN 10% 20%, 30%

3 13. CONTRACTOR: must attach Liability (Acord form and Workmens' Comp) - applications will not be accepted without proper insurance NAME MAILING ADDRESS PHONENUMBER~: CELLNUMBER~: ADDRESS: INSURANCE INFO: (check which apply) liability workers' comp workers' comp exempt BP-l H/O/X A copy of your Liability and Workers' Comp insurance forms must be submitted with this application 14. COST OF CONSTRUCTION $ --.;( INCLUDING ALL LABOR AND MATERIALS) Upon acceptjn" this permit. you have acknowled"ed that you are required to notify this office a minimum of 48 hours in advance for Inspections that pertain to your project, A list of inspections will be attached to the required on site buildioll plans which will include mur permit, Dig Sa/ely Master Member List By law, Excavators must call Di" Safely, New York at %2 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 of the Dig Safely. New York "one-call" notification system,note:this list does not contain members in any villages or cities that may edst 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 and the HIGH FALLS WATER DISTRICT I (we) understand that it is a violation o/the Town 0/Marbletown Zoning Law to use loccupy withoutfirst obtaining a CertifICate o/occupancy I Compliance/rom the Codes En/orcement Officer. MAXIMUM $250,00 I WEEK AND OR IMPRISONMENT,}, (we) the undersigned. understand that any Incomplete or omitted In/ormation on plans and (or) description o/work as submitted to the building department/or the issuing 0/a building permit shall be constructed Iinstailed in compliance with all applicable rules, regulation and codes In effect at the time 0/this signing. I hereby grant the building inspector or his or her authorized agent permission to enter upon the premises and into any building or building structures thereon at anytime during working hours without being subject to arrest or civil suit/or trespassing. I (we) understand that ifa permit isissued, it is valid/or one year 0/date 0/issuance and a lee 0/$25.00 or 10% 0/the original permit lee (whichever is higher) will be applied/or renewal each year thereafter ifapplicable..,..,... -.,-"...-_~ Date:----- Signature ofowner (s) Signature '"'~~~~~~h.rr.~ /~mrn~~~~~ Date:----- of Contractor/Bulider Signature 01 Applicant Where would you like the permit to be sent after processing..ipermit to be mailed to homeowner's mailing address --"permit will be picked up Name & # to call when ready OFFICE USE ONLY ) Building Permit ) Zoning Permit ( ) Referred to Planning Board ) Referred to Zoning Board Z B SF CCF 6, 12 S/BIL# ZONING PERMIT: )APPROVED ) DENIED ) DISAPPROVED REASON, ZONING PERMIT NUMBER DATE, BUILDING PERMIT: ()APPROVED ) DENIED ( ) DISAPPROVED REASON BUILDINGPERMITNUMBER DATE FEES PAlO: ZONING PERMIT FEE $ CHECK BY: OWNER, BUILDING PERMIT FEE $ CHECK NUMBER CASH OTHER $ BANK: TOTAL AMOUNT DUE $ RECEIPT #: ~D:s.at~e"'_:

4 TypicaJ DetaHsfor Deck Plans Marbletown Building Safety Department Leoger Board Details: Flashing /Detail Bolt t ~ Size & Flashing (Required)... / l Ai ledger Board / (Bolt to Structure) \Back Flashing Wall Canterlever Joist Details: Spacing (O/c): / Joist Decking Stair Details' Riser Height Total # of Handrail Required? YES or NO (Circle Answer) (If # of risers then yes.). Guards Tread NOSing Overhang: Guards Required? YES or NO (Circle Answer) (If total stair rise is >30 inches, Ihen yes.) Tread (Min. 9 inches) MetalHangers " Post (Min. 4x4 inches) p /.,./ Nosing "ti Riser (Max. 8 1/4 inches) Slab Footing Frost-Protected Foundation Girder Details: Size & Min. Bearing LJ Min. 48 inches Min. Dimension Below Grade / of Footprint '-... is 12 inches Decking Max. Height Above Grade:. Guards Required? YES or NO (Circle Answer: (If maximum height above grade >30 inches, then yes.) \ '

5 HOMEOWNER'S EXEMPT FORM (BP l) Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance Coverage for a 1,2,3 or 4 Family, Owner-occupied Residence **This form cannot be used to waive the workers' compensation rights or obligations ofany party. u Und~r.p~nalty 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. D 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 perfonn such work. D I have a homeowners insurance policy that iscurreritly in effect and covers the property listed onlhe attached building pennit AND am hiring or paying individuals a total of less than AOhburs p r week (aggregate hours for all paid individuals on the jobsite) for which the building pennit wasi:ssued. I also agree to either: + acquire appropriate workers' compensation coverage and provide appropriate proof of that ceverage on.. fonnsapprovedby the Chair of the NYS Workers' Compensation Board to thegovernmentenjltyissuing >ihe'buhdlngpermit ifj need to hire or pay individuals a total of 40hours or more perweek(aggreg~te hours for all paid individuals on the jobsite) for work indicated on the building pennit. or ifapproptiate,file ace 200 exemption fonn; OR + have the general contractor, performing the work on the 1,2, 3 or 4 family, owner..occupiedresidence (including condominiums) listed on the building petrnit that I am applying for, provide appropriate proofof workers', compensation coverag,e or proofofexemption from that coverage on forms approved bythe Chair bfthe NYS Workers' Compensation Board to the govemmententity issuing the building permit if the project takes a total of40 hours or more per week (aggregate hours for all paid individuals on thejobsite) for work indicated on the building pennit. (Signature of Homeowner).. '(Homeowner's Name Printed) Property Addiessthat requires the building penn it: (Date Signed).Home Telephone Number... ' ". ". '.".", to Inefore me thl$.... day of Once notarized;tbis DP t form serves as an exemption for both workers' compensation and disability benefits IDsuraD:ce,:tove,ra~e. BP-l (12/08) HOMEOWNERS EXEMPT FORM (BP 1) NY WCB

6 LAWS OF NEW YORK CHAPTER 439 Tl:e general munidpallllw is amended by adding a new section 12.5 to read as follows:. 12S. ISSUANCE OF BUILDING PERMITS. NO CITY, TOWN OR VILLAGE SHALL ISSUE A BUILDING PERMIT W1THOUTOBTAINING FROM THE PERMIT APPLICANT EITHER: 1. PROOF DULY SUBSCRIBED THAT WORKERS' COMPENSATION INSURANCE AND DlSABILlTYBENEFI1'S COVERAGE rssued BY AN INSURANCE CARRIER IN A FORM SATISFACTORY TO THE CHAIR OF THE WORKERS' COM;P:ENSATION BOARD AS PROVIDED FOR IN SECTION FIFTY SEVENOF THE WORKERS' COMPENSAUON 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 oftbe General Municipal Law 1..GeneralContradors - Business Owners ilnd Certain Homeowners.. gqr buii~esse.sand certain bomeowners listed lis the general contractors on building permits, proof that they are in comp'im<i~ With Section 570f theworkers'compensaticln Law (WCL)is ONE ofthe following formsthatindioate that they~: insured (C ] 05.2 or U 26.3). self.itlsured (SI-l2). or are ~xen1pt'(ce~200)... un'd~t; the mlitdatorycovetage provisions of the WCI.,. Any residence that is not II 1, l,30r4 Fa:milYtQper~g,t,el!Dled ~Id~.~eis col1$id~red a business (income or potential income property) and milst prove compliance.byfllillg o.ne;l)fthe,abgv f9rms.., 2. Owuer-occupied Residences F9rhomeoWIl~r$ ofa 1,1, 30r 4 Family, Owner-ocsupiedResldence, proof ofth.eir exemption from the mandatory~pverage. provl~ion. oftile Workers'Compensation Law when applying for a building permit is to file fonn BP t...'.:. Form BP lshall be flied ifthe he'ineowner ofa l,2 i 3:or4 Famlly,Owner occqpied.resideij'ce is liswd'4s the geoeral contractor on the buijdingpermit. and the homeo}vner: o. is performing all the work for which the building permit was issued hlmlherself. o is 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 the homeowner perform such work. or o has a homeowner's insurance policy that is currently in effect and covers the property for which the b.uilding permit was issued AND the homeowner is hiring or paying individuals a total of less than 40 hours per week (aggregate hours for all pald individuals on the jobsite) for the work for which the building permit W8.S1ssued. f#ih~'hbjfi~w:tteto:f,a '1 ~1, 30r 4F"n;tUrf~e'r.occupjed ResIdence is hiring or paying individuals a total of 40 hour's or MORE in any week (aggrt!gate ho~\for all pllid individuals on the jobsite) for the work for which the building permit was issued. then the homeowner~tnay not tile the "Affidavit ofexemption"form. BP l(11104). bljtsh~l1. either:... o acquire appropriate workers' compens~tjon coverage and provide appropriate proofofthat coverageonfotms approved by.thechalr of the NYS "Workers' Compensation Board to the government entity issuing the building permit (the C \ 05.2 or U 26Jform), OR have the general contractor, (perfonl\ing the work on the 1, 2, 3 or 4 family, owner-occupied residence (including condominiums) listed on ~building pennit) provide appropriate proofofworkers' compensation ~,\lera.gt:}. or proof of~~emption frclm)hat coverage on fonns approved by the Chair of the NYS Workers' Compet.lsation B6ardtothe government entity issuing the building permit. BP"l(12/08) Reverse