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APPLICATION FOR BUILDING /
ELECTRICAL / MECHANICAL /
PLUMBING PERMIT
Application Checklist
□ Permit Application
□ Insurance Certificates
□ Worker's Compensation Statement
□ Copy of Westchester County License
□ Application Fee
□ Permit Fees
□ Three (3) sets of Plans.
□ Electronic version of Plans in PDF format.
Note: Incomplete applications will be returned without
review.
A standard two (2) week review timeframe by the Building
Department is typical for all applications. Additional time is
required based on the extent and scope of work proposed.
Village of Elmsford BUlLDING DEPARTME T
I 5 SOUTH STONE A VENUE, ELMSFORD, NY I 0523
TELEPHONE (914) 345-1553
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Permit No.: ____ _
Date:. ______ _ Village _of Elmsford Total Fee: _______ _
BUILDING DEPARTMENT
Plans: D Yes D No 15 SOUTH STONE AVENUE, ELMSFORD, NY 10523
Building Dept (914) 345-1553
Fax (914) 592-8129
BUILDING/ELECTRICAL/PLUMBING PERMIT APPLICATION
Application is hereby made to the Building Department for the
issuance of Permits pursuant to the Code of the Village of
Elmsford. 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 Elmsford 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.
Application Fee: ____ _
APPLYING FOR: D Building Permit □Electrical Penni! D Plumbing
Permit D HV AC System Permit D Fire Suppression/Alarm Permit
TYPE OF WORK:
SITE DATA:
D Residential (new) D Commercial/Business □DemolitionD Interior
Demolition Only
D Residential (addition/alteration) D Assembly (includes
restaurants) D Pool/Deck/Patio/Fence D Antenna(s)
Zone: __ Section - Block - Lot:___ _ __
Street Address: _______________________ _
□Accessory StructureDrndustrialDoil Tank Removal or
Abandomnent□other _____ _
Project Description ---------------------------------------
The following information is to be completed in full. Address
must include Street, City, State, and Zip.
OWNER:
Name: ____________________________ _
Address: Phone: _______ _
Mobile:. _______ _
Email:. _______________ _
LESSEE:
Name: __________________________ _
Address:
APPLICANT: Applicant is: D Owner D Lessee D Contractor
Phone: _______ _
Mobile:. _______ _
Email:, _______________ _
D Other (complete below in full) ---- - - -----
Name: __________________________ _
Address: Phone: _______ _
Mobile: _______ _
Email: _______________ _
(Form continued on back)
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ARCHITECT/ENGINEER
Name: __________________________ _ (New Yoric State Regiotration
If)
Address: Phone: _______ _
Mobile: ______ _
Email:. ______________ _
CONTRACTOR: 0 General Contractor O Electrician □ Plumber D
Mechanical 0Fire Suppression/Alano
Nanie:. __________________________ _ (Westchester County
License# if applicable)
Address: Phone: _______ _
Mobile: ______ _
Email:. _______________ _
Permit Fee:. _____ _
COST OF CONSTRUCTION ORV ALUATION:
Cost of Construction or Valuation$.__________ (Valuation or
Costs for the work described in the Application for Building Permit
include the cost of all of 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. _________ _ Print Name: ___________________
_
Notary Public:. _______________ _ Seal
DO NOT WRITE BELOW THIS LINE FOR OFFICIAL USE ONLY
Building Department Review By: _________ _ Date: ___ _ D
Disapproved O Approved
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Village of Elmsford BUILDING DEPARTMENT
15 SOUTH STONE AVENUE, ELMSFORD, NY 10523 Building Dept (914)
345-1553
Fax (914) 592-8129
PROXY STATEMENT
Proxy is required for all applications (Building, Electrical,
Plumbing, Mechanical, Sign, Architectural Review.) when anyone
other than the Owner is signing the application.
State of _______ _, ss:
County of ______ _,
Date: _____ _
_____________________ being duly sworn, deposes and says the
he/she resides at (Owner's full name)
_______________ in the County of _________ and the State of
_____ _ (Street, City/Town) (County) (State)
and that he/she is the owner of _________________ , the premises
described in the attached (Street Address)
application and that he/she has authorized _____________________
to make the attached (Applicant Name)
application for _________________ and to represent them at all
Board and/or Commission (Application Type)
meetings.
Sworn to before me this
______ day of ________ , 20 __ Signature of Owner
Notary Public or Commissioner of Deeds Seal
FOR VILLAGE USE ONLY
APPLICATION No.: ______ _ or PERMIT No.: ______ _
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Village of Elms/ ord BUILDING DEPARTMENT
15 SOUTH STONE A VENUE, ELMSFORD, NY l 0523 TELEPHONE (914)
592-6555
Fees for Building/Electrical/Mechanical/Fire Suppression/
Alarm/Plumbing Permits
Building/Mechanical/Fire Application Fee $160.00 Non-refundable
fee to be submitted Suppression Permits with application
For all work performed Permit Fee less than $6,000 $75.00
without a permit an in construction cost additional administrative
Pe1mit Fee $6,000.00 in $12.50 per $1,000 Example: $50,000
construction cost fee is due equal to the construction cost and
greater of construction cost 50,000/1,000 = 50 permit fee
calculated.
50 x 12.50 = $625.00 Fee Contact the Building
Temporary Certificate of $150.00 Department to confirm
Occupancy Permits required to be issued. Certificate of
Occupancy $100.00
Certificate of Completion $50.00
Minor Permits: Permit Fee (Application Fee $110.00 Residential
Roofs, Fences, is Waived) Sheds
Permit Fee for construction cost $6,000 and greater:
Construction Cost: $ Fee:$
Administrative fee for work without a permit. (Equal to Permit
Fee) Fee:$
Electrical / Alarm System $0 to $499 $60.00 Permits $500 to $999
$70.00 (based on construction cost)
$1,000 to $1,999 $80.00
$2,000 to $3,999 $90.00
$4,000 to $9,999 $135.00
$10,000 to $50,000 $200.00 +2% Example: $30,000 construction
cost 30,000 X 2% = 600 $200 + $600 = $800.00 Fee
greater than $50,000 $1,500.00
Permit Fee:
Construction Cost: $ Fee:$
Plumbing Permit Application fee $50.00
(See back for Plumbing Additional Fee $5 per fixture Example: 5
fixtures (toilet, lavatory Fixture worksheet) sink, tub, kitchen
sink, laundry sink)
5 X $5 = $25 $40 + $25 = $65.00 Fee
Permit Fee:
number of fixtures x $5 = $ +$50 = Fee:$
Demolition Permit Permit Fee per structure $200.00 Fee:$
The Building Permit application fee must be submitted as a
separate check and is non-refundable. If the applicant withdraws
the application the Permit Fee will be refunded less charges for
time already expended in review of the
construction documents.
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Plumbing Fixture Table Fixture Location and Number of
Fixtures
.. .. .. I-, 0 .. .. 0 0 .. 0
I-, 0 0 .. 0 0 ..
� 0
� .. � .. �
0 0 .. 0 0 0 0 - 0 0 - 0 0 i£ = 0
i£ .5! £ =
£- f.(
£ £ � � -c::, -= f.( -= � -c::, f.( -= -= 8 - 8 .... = -c::,
.... = = -c::, .... =� .... 0 ,.. '"' -= -= � � .... 0 '"' .. -= -=
� "' "' (.I :a = ·� ....
t "' � ..... = �
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-�C,I >
Fixture Type = rZ � 0 Fixture Type = rZ � -= 0 -� � = 00 E-t
i;;. i;;. 00 00 = 00 E-t i;;. i;;. 00 00
AIR CONDITIONER HUMIDIFJER
BAR SINK ICE MAKER
BASIN/LAVATORY OTHER FIXTURES
BATHTUB ROOFDRAIN
BEVERAGE DISPENSER SERVICE/MOP SINK
BIDET SEWER EJECT PUMP
COFFEE URN/MAKER SHAMPOO BASIN
CONDENSATE DRAIN SHOWER
DENTAL CHAIR/UNIT SINK
DISHWASHER SLOP-SINKS
DISPOSAL STEAM TABLE
DRINKING FOUNTAIN SUMP PUMP
FLOORDRAIN SWIMMING POOL
FLOOR SINK/0. S.D. TUB/WHIRL POOL
GAS BOILER URINAL
GASDRYER VACUUM SYSTEM
GAS FRYER WASH TRAY
GAS FURNACE WASH-BASINS
GAS GRILL WASHING MACHINE
GAS MISCELLANEOUS WATER BOOSTER PUMP
GAS OVEN/BROILER WATER CLOSET
GAS POOL/HOT TUB HTR WATER HEATER
GAS RANGE/WOK
GAS ROOF TOP UNIT
GAS SPACE HEATER
GAS STOVE
GAS WATER HEATER
HOSE BIB/ HYDRANT
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Village of Elmsford BUILDING DEPARTJvIBNT
15 SOUTH STONE AVENUE, ELMSFORD, NY 10523
TELEPHONE (914) 345-1553
Instructions for Filing for a
Building/Electrical/Plumbing Permit
Fill out all spaces on the pe1U1it application·. All
info1U1ation is essential and no application for permit will be
reviewed w1til all information is provided. Initial submission of
an application is not considered complete for review for a
Building
. Permit Wltil all other required approvals are granted.
At the discretion of the Building Department an initial review
may be performed to determine if any Uniform Fire Prevention and
Building Code issues may need to be addressed in future
submissions. If such a review is performed it does not constitute
acceptance of the docwnents for the Final Review Submission.
If the proposed work requires referral to the Village Board,
Architectural Review Board, and/or Zoning Board of Appeals the
Building Department will issue a letter of denial and/or refer the
application to the appropriate Board. If a letter of denial is
issued it must accompany all applications to the Zoning Board of
Appeals. Additional copies of all plans and specifications will be
required per each Board's needs.
Review of Final Construction Documents in consideration for
issuing a Building Permit will not be performed W1til all other
required approvals are granted. They include but are not limited to
the following: Site Plan, Subdivision, Architectural, Zoning, and
Environmental. Official Date of Submission for Final Review will be
considered as the next standard business day after other required
approvals are formally granted or passed. The Codes in effect at
the Official Date of Submission will be used for the Final
Review.
All applications require the standard permit application to be
filled out. IE: Plumbing and Electrical. If the work to be
performed is strictly Plwnbing or Electrical only, the standard
building permit application and building permit fee will be waived.
The individual Electrical and Plumbing Permit fees are still
applicable. (See the "Fees for Building/Electrical/Plumbing
Pem1its" worksheet included in this permit application package) All
applications must be submitted before any pennit is issued.
D The Section, Sheet, Block, and Lot nWllbers must be provided
as given on the Village Tax Map.
□ If the applicant for any permit is not the owner of the
property where the work will be performed a completedProxy
Statement must be completed for any type of work.No Exceptions.
D Submit along with the required forms three (3) copies of plans
and specifications signed and sealed by a designprofessional
licensed in the State of New York. All plans must be folded, not
rolled. All plans must be sealed bya design professional licensed
in the State of New York except as exempted by NYS Education Law
with priorapproval of the Code Enforcement Official.
Note: Incomplete applications will be returned without
review.
A standard two (2) week review timeframe by the Building
Department is typical for all
applications. Additional time is required based on the extent
and scope of work proposed.
Construction documents shall not be accepted as part of an
application for a building permit unless such
documents:
D Are prepared by a New York State registered architect or
licensed professional engineer where so required by the Education
Laws.
D Indicate with sufficient clarity and detail the nature and
extent of the work proposed.
□ Identify the occupancy classification of any affected building
or structure.
D Substantiate that the proposed work will comply with the
Unifonn Code and the State EnergyConservation Construction
Code.
Additional Instructions on Back
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Permit No: Total Fee: Date: Application Fee: Dother: Section
Block Lot: undefined: Zone: undefined_2: Street Address: Project
Description: Name: Phone: Address 1: Address 2: undefined_3:
undefined_4: Mobile: Email: Name_2: Phone_2: Address 1_2: Address
2_2: undefined_5: undefined_6: Mobile_2: Email_2: Name_3: Phone_3:
Address 1_3: Address 2_3: undefined_7: undefined_8: Mobile_3:
Email_3: Name_4: New York State Registration If: Address 1_4:
Address 2_4: Phone_4: undefined_9: undefined_10: Mobile_4: Email_4:
Name_5: Westchester County Llccnsc if applicable: Address 1_5:
Address 2_5: Phone_5: undefined_11: undefined_12: Mobile_5:
Email_5: Permit Fee: Cost of Construction or Valuation: State ofNew
York County of: being duly sworn: this: day of: PrintName: Notary
Public: DO NOT WRITE BELOW TlllS LINE FOR OFFICIAL USE ONLY:
Building Department Review By: Date_2: Date_3: State of: County of:
Owners full name: Street CityTown: in the County of: and the State
of: and that heshe is the owner of: application and that heshe has
authorized: application for: undefined_13: day of_2: 20: Notary
Public or Commissioner of Deeds: APPLICATION No: PERMIT No: Check
Box1: OffCheck Box2: OffCheck Box3: OffCheck Box4: OffCheck Box5:
OffCheck Box6: OffCheck Box7: OffCheck Box8: OffCheck Box9:
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