APPLICATION CHECKLIST. Workers Compensation Certificate (C or waiver) Three (3) sets of Architectural Plans, signed and sealed (if applicable)

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1 VILLAGE OF OSSINING BUILDING PERMIT APPLICATION Applications must be submitted in person. Applications submitted by mail, or fax will not be accepted. APPLICATION CHECKLIST Completed Permit Application Insurance Certificates, Liability Insurance Workers Compensation Certificate (C or waiver) Disability Certificate (DB ) Copy of Westchester County License Permit Fee Three (3) sets of Architectural Plans, signed and sealed (if applicable) Completed Owner Authorization Form (if applicant is other than homeowner) Manufacturer Specifications (is applicable) Licenses and certificates for all associated subcontractors Note: Incomplete applications will be returned without review. Applications must be submitted in person. A standard four to six (4-6) week review time frame by the Building Department is typical for all applications. Additional time is required based on the extent and scope of work proposed and response by your design professional. Building Department will review each application via submittal date basis but we will try our utmost to expedite your application. Village of Ossining John-Paul Rodrigues Ossining Operations Center Building Department 101 Route 9A, PO Box 1166, Ossining, NY Telephone (914) Fax (914)

2 Village of Ossining John-Paul Rodrigues Ossining Operations Center Permit No: Date: BUILDING DEPARTMENT 101 Route 9A, Ossining, NY Phone (914) Plans: Yes No Fax (914) Total Fee: BUILDING PERMIT APPLICATION Application is hereby made to the Building Department for the issuance of Permits pursuant to the Code of the Village of Ossining. The applicant agrees to comply with all applicable laws, ordinances and regulations. The applicant attests that the proposed work outlined in this application conforms to all provisions of the Code of the Village of Ossining and laws of New York State. It is further agreed that the premises will not be occupied until a Certificate of Occupancy has been issued and all fees are paid in full. APPLYING FOR (check all applicable): Building Permit HVAC System Permit Fire Suppression/Alarm Permit TYPE OF WORK: Residential (New) Residential (Addition/Alteration) Accessory Structure Commercial/Business Assembly (Includes Restaurants) Industrial Telecommunications Pools/Deck/Patio/Fence Other Oil Tank Removal or Abandonment Licenses and certificates for all associated subcontractors will be required at time of application. SITE DATA: Zone: Section-Block-Lot: Street Address: How many families: Project Description: Will electrical or plumbing work be associated with this permit? YES NO If YES, a Westchester County licensed electrician or plumber will be required. The following information is to be completed in full. Address must include street, city, state and zip. OWNER: Name: Home Phone Address: Cell Phone APPLICANT: Applicant is Owner Lessee Contractor Other Name: Home Phone Address: Cell Phone

3 ARCHITECT/ENGINEER: Name: NYS Registration Address: Home Phone Cell Phone CONTRACTOR: Name: Westchester County Lic. # Address: Home Phone Cell Phone SUBCONTRACTOR: HVAC System Name: Westchester County Lic. # Address: Home Phone Cell Phone SUBCONTRACTOR: Fire Suppression/Alarm Name: Westchester County Lic. # Address: Home Phone Cell Phone SUBCONTRACTOR: Other (specify) Name: Westchester County Lic. # Address: Home Phone Cell Phone

4 COST OF CONSTRUCTION VALUATION: Cost of Construction Valuation $ Valuation or costs for the work described in the Application for Building permit include the cost of all the construction and other work done previously without permit or new in connection therewith, exclusive of the cost of the land. The estimated cost shall include all costs related to the above described project and shall include all labor that is utilized, whether donated or contracted, including that of the property owner. If a reasonable valuation or estimate for construction is not provided, the Building Inspector shall determine the amount. If the final cost is less than the estimated cost stated in this Application for Building Permit, no portion of the fee paid upon the filing of the Certificate of Occupancy/Compliance application will be refunded. AUTHORIZATION: State of New York, County of being duly sworn deposes and says they are the owner or authorized representative by attached completed proxy statement and are duly authorized to perform or have performed said work and to make and file this application; that all statements are true and to the best of their knowledge and belief, and that the work will be performed in the manner set forth in the application and in the plans and specifications filed therewith. Sworn to before me Owner or Authorized Representative Signature: This day of 20 Print Name: Notary Public: Seal INSURANCE: A. Certificate of Liability Insurance naming Village of Ossining, 16 Croton Avenue, Ossining, NY as certificate holder and additional insured. The job location must be referenced on the certificate. B. Certificate of Insurance for Workers Compensation (Form C-105.2) and New York State Disability (Form DB-120.1) with Village of Ossining, 16 Croton Avenue, Ossining, NY as certificate holder. Acord is not acceptable for these policies. C. If there is no Workers Compensation Policy, a waiver must be submitted by the Workers Compensation Board. D. Westchester County License. E. If homeowner is doing the work, a Workers Compensation waiver and an Acord Certificate of Homeowner s Liability Insurance must be submitted with your application. The Acord Certificate of Liability should be obtained from your insurance agent. DO NOT WRITE BELOW THIS LINE FOR OFFICIAL USE ONLY Building Department Review By: Date : DISAPPROVED APPROVED

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