Building Permit Fees
Are Non-Refundable

CHAUTAUQUA COUNTY, NEW YORK

(CITY, TOWN, VILLAGE) OF ________________________

INFORMATION FOR BUILDING AND ZONING PERMIT

* Applicant _______________________ Fee Paid _____

* Address ________________________ Permit #_____

_________________________________ * Date ___________

_________________________________

* Phone ____________ Signed ____________________

Application Date__________Application # ____________

Approved _____ Disapproved _____

Zoning Variance Required? _____ Special Use Permit?______

Site Plan Review______________ Date ___________

Zoning Board Approval/ Disapproval Date__________

Other Board Approval/ Disapproval Date__________

Inspections Required for Certificate of Occupancy

(signed by inspector)

Foundation_____________________ Date__________

Framing _____________________ Date__________

Plumbing _____________________ Date__________

Electrical _____________________ Date__________

Well/Septic ____________________ Date__________

Site Plan inspection______________ Date__________

Final __________________ Date__________

Health Department Review Required? __________

Date Completed__________

Certificate of Occupancy #_____________ Date__________

Certificate of Compliance #____________ Date__________

* Must Be Filled In

Name ________________________*Address _____________________________ Permit No.______________

______________________________

_______________________________

*Approved ________Disapproved____________ Date Issued _______________

*Permit For________________________________________________________________________________

*Location___________________________________*Section____________Block_________Lot__________

CHAUTAUQUA COUNTY, NEW YORK

(C1TY, TOWN, VILLAGE) OF ________________

APPLICATION FOR BUILDING AND ZONING PERMIT

Note- No permit for new construction will be issued unless this application is properly filled out. At least two sets of plans, specifications, and a plot plan (see page four) must be submitted with this application.

INSTRUCTIONS

1. This application is to be filled out by typing or printing and must be submitted to the Building and Zoning Officer of the ______________of____________

2. Thc work covered by this application shall not be commenced before issuance of a Building Permit by the Building and Zoning Officer.

3. Upon approval of this application, the Building and Zoning Officer will issue a Building Permit to the applicant. Thc Building Permit shall be posted upon the premises in a conspicuous place so as to be visible from the street throughout the period of construction.

4. No structure or use for which a Building Permit has been issued shall bc occupied or used in whole or in part upon completion for any purpose until a Certificate of Occupancy shall have been granted by the Building and Zoning Officer.

* Owner (if different from applicant)

Name________________________ * Contractor______________________

Address______________________ Address_________________________

_____________________________ ________________________________

_____________________________ _______________________________

Phone______________________ Phone______________________

Certificates Received?____ General Liability_______________

Insurance Company Name_____________________________#________________________
(Last two types not required for sole proprietorships or partnerships without employees)

Architect/Engineer Stamp Required?_______ Name_____________________________

Electrician_________________________ Plumber______________________________

Affidavit

STATE OF NEW YORK
SS:___________________

CHAUTAUQUA COUNTY

I swear that to the best of knowledge and belief the statements contained in this application, together with the plans and specifications submitted, are a true and complete statement of all proposed work to be done on the described premise, and that all provisions of the Building Codes and Zoning Codes and all other laws pertaining to the proposed work shall be complied with, whether specified or not, and that such work is authorized by the owner. I acknowledge that zoning code information relating to applicant's district has been received.

Signature of Owner_____________________________Date__________________
                          (Architect. Contractor, Owner,)

Sworn before me this day of ,20____

_____________________________
         Notary Public

Construction information

New Construction ____ Addition ____ Alteration _____

Other (please explain) ___________________________________________

* Location ___________________________________________

(Street number and name)

* Tax Map: Section _____ Block _____ Lot _____

Size of Lot _____X_____X_____X_____ Zoning District _____________

* Cost of Project ___________ Size (Square Feet) ________ # of Families______

Date Work to Start__________ Date of Completion (Approximate)____________

Bui(ding Type ___________________________________

lntended Use ___________________________________

Foundation Type _______________ Roof Material ________________________

Exterior Walls _______________ Interior Walls ________________________

Heating Facilitjes _______________ Chimney Construction __________________

Water Source: Well ______ Municipal _______ Engineer's Stamp:_____Fee Paid ____

Sewage Disposal: Public ____ Private______ Perc_____ Fee Paid ______

Driveway Required? ____ Date ___________ Highway Sup.__________________

Parking Lot Permit _____ Sign ________ Flood Plain _______

If Mobile/Double-wide, HUD ___________________ NYS _________________

Model Number ______________ Serial Number _______________ Year __________

State Permits Required?

SEQRA _____Wetlands _____Stormwater Management ________________________

Right-of-way Permit ______ Easemenl ______ UFPO # ________________________

* PLOT PLAN

1. This page shall be used for the drawing of a plot plan for all major construction and additions
and in such other cases as the Building and Zoning Officer deems necessary.

2. The plot plan shall show the location and size of the lot, locations and sizes of buildings and
structures upon the premises (both existing and proposed) and their relationship to adjoining
premises and public streets.

3. Locate and label clearly and distinctly all buildings and structures, show widths and depths of
all yards show names of all streets and indicate north with an arrow.

4. Distance from building to street line:_____ feet. Distance to nearest building at rear:
feet and on each side: _____ feet. Distance from building to rear lot line_____ feet.
Distance from building to each side lot line: ____ feet.

SHOW DISTANCE FROM BUILDING TO SIDE. FRONT AND REAR LOT LINES

Rear of Lot _______ft.

Frontage of lot ft.

Street name _________________________