Identification of Applicant

VILLAGE OF MILLBROOK
APPLICATION FOR BUILDING PERMIT
BUILDING INSPECTOR: KENNETH McLAUGHLIN
PHONE/TEXT: 845-240-2118 FAX:845-677-3972 OFFICE HOURS: MONDAYS 5-7 PM AT VILLAGE HALL
ADDRESS: VILLAGE OF MILLBROOK PO BOX 349 35 MERRITT AVE MILLBROOK NY 12545

IDENTIFICATION OF APPLICANT

NAME OF OWNER ______PHONE NO.: ______

PARCEL GRID NO. ______PHYSICAL ADDRESS:______

MAIL ADDRESS ______STATE:______ZIP CODE:______

APPLICANT'S NAME:______PHONE NO.:______
E-Mail (for e-copy of Building Permit):______
(if applicant is not the owner of the property, owner of property MUST sign at the bottom of application)

DESCRIBE THE PROPOSED WORK FOR THIS APPLICATION: (PLEASE CHECK) ALTER ☐USE ☐ERECT☐

□ ACCESSORY BUILDING □ ADDITION □ ALTERATIONS □ INSULATING

□ DECK/PORCH/SUNROOM □ POOL/HOT TUB □ STRUCTURAL REPAIRS

DESCRIPTION OF WORK TO BE PERFORMED AND CONTRACTOR’S NAME AND PHONE NUMBER:
______

______

______

DIMENSIONS: ______X ______TOTAL SQ. FT. ______ESTIMATED COST* $ ______

ATTACH THE FOLLOWING DOCUMENTS AS PART OF THIS APPLICATION
(Please check appropriate boxes)

□ A PROPERTY SURVEY OR COPY OF THE APPROVED PLOT OF THE AFFECTED PREMISES

□ CONSTRUCTION PLANS & SPECIFICATIONS (2 SETS IF ARCHITECTURAL PLANS)

□ ZONING WORKSHEET

□ PROOF OF WORKMAN'S COMPENSATION INSURANCE ON FORM #C-105.2 OR U26.3 BY THE CARRIER

☐PLEASE CHECK IF YOU OR OWNER IS AWARE OF ANY EASEMENT/S. IF YES, PLEASE PROVIDE A COPY OF AFORESAID EASEMENT/S. NOT PROVIDING A COPY OF THE EASEMENT/S MAY RESULT IN A DELAY IN ISSUANCE OF YOUR BUILDING PERMIT AND/OR CERTIFICATE OF OCCUPANCY.

APPLICATION IS HEREBY MADE TO THE OFFICE OF THE BUILDING INSPECTOR, DEPARTMENT OF PLANNING, ZONING AND BUILDING PURSUANT TO THE N.Y.S. UNIFORM FIRE PREVENTION & BUILDING CODE & THE CODE OF THE VILLAGE OF MILLBROOK AS ADOPTED BY THE VILLAGE BOARD. THE APPLICANT AGREES TO COMPLY WITH ALL APPLICABLE LAWS, ORDINANCES & REGULATIONS.

SIGNATURE OF APPLICANT ______DATE ______

SIGNATURE OF OWNER ______DATE______

**************************************OFFICE USE ONLY ****************************************

ZONING FEES $ ADMIN. FEE $ :______BLDG. PERMIT FEES $______RECEIPT NO. ______DATE: ______

APPLICATION NO.:______DATE: ______BUILDING PERMIT NO.: ______DATE: ______

Building Department Fees:

First thousand dollars ($1,000.00) or less in estimated value $ 50.00 $______
Over $1,000.00 in value up to $20,000: $3.00/ Thousand
For each additional thousands or fraction thereof + $______
Over $20,000: $2.00/Thousand + $______
For each thousands or fraction thereof
Total: $______

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