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13-7508I~O~1'!~ tit~PER~~15(1R li;trhara (~uVicr LO111'G :~D111Nti1"1 RATO12 13;irbara Roberti A 1 'h l.011NG tik~:CRET.aRI dui I\l»C \ 1 ~~ October 24, 2013 To: Michael Leonard Town Clerk From: Sue Rose, Secretary Town of Wappinger Zoning Board of Appeals Re: Oswald & Mary Mantilla Appeal No. 13-7508 7oninr Board uf:Aplteais lla~~ard 1'ra~~er. Ch~:irman l ont I:lrllaccutt ,~l C'aelltt Rt~hert ,ltthnston Meter Gnlotti L_~ oeic~y,~ Attached you will find the original Application/Decision & Order for Oswald & Mary Mantilla, 149 Cider Mill Loop Grid # 6258-04-824140. I would appreciate it if you would file these documents. Attachments cc: Oswald & Mary Mantilla Town File Building File Jim Horan TO~'~' N OF ~'VAPP'IN GER ZONING I~OARD OF AI'I'EALS ~n n1IDD1.La3L!SI I f:i);~U ~1~.~A~'I'INC;EI:S r.~i_t.s. n~~ I~;qt) say-~~,;-~,~~~, TOWN OF WAPPINGER P.O. Box 324 -- 20 MIDDLEBUSN ROAD WAPPINGERS FALLS, NY 1 2590 Zoning Board of Appeals Office: 845.297.1373 ~ Fax: 845.297,4558 Zoning Enforcement Officer ~~ Office : 845.297.6257 T~~~~~~ www.townofwappinger.us 1 1 Application for an Area Variance ~~ ~~75a~ Appeal # Dated : u 12'3 ~ 2013 NEW YORK: TOWN OF WAPPINGER, TO THE ZONING BOARD OF APPEALS, Man~'k esiding at L~c(~. M, l l ~P I(We), ug aatcl J I~".sn~ita e. 11~~A - ~~,~_ IDB~ (phone), hereby appeal 12S o ' to the Zoriing Boar of Appeals from the decision/aclti fo oan area va gan e(sjistra~or,, dated 9 ~ ~,(. , ZB®~-~ and do hereby app y ~ y ~5~~' ~~~- -~ n.. _ _ ~,. „~~ Premises located at - Q ~ _ ~ 8 y ~ `/ D Tax Grid # ~ ~~ Zoning District . ert Dti std J * ~~~ 4 Ma..~~-I.- 1. Record Owner of Prop Y W ~ ~ ~ Address 14 ~~~' M.il Phone Number ~-~' ~°~`~ ~' ~~~~~'~ q~ Z$ ~ 3 Signature: ~r Owner Consent: Dated: printed:" c^s~~°`"0 ~AN~"`a ~'~-~''" ~,9.Y,~~''i1 2. Variance(s) Request: Variance No. 1 eats for a variance(s) of the following I(We) hereby apply to the Zoning Board of App requirements of the Zoning Code. (Indicate Article, 35~~ ,Subsection and Paragraph) Required: x'0"1' .~ Applicant(s) can prov de: ~ (s co Thus requestin U ~"~ ~ ~, To allow: ~- ~' ~~ TO\\'022.7_6,4-AAV (4-0. Rcr) 1 of 4 Town of Wappinger Zoning Board of Appeals Application for an Area Variance Appeal No, Variance No. 2 eats for a variance(s) of the following I(We) hereby apply to the Zoning Board of App requirements of the Zoning Code. (Indicate Article, Section, Subsection and Paragraph) Required Applicant(s) can provide: Thus requesting: To allow: 3. Reason For Appeal (Please substantiate the request by answering the following questions in detail. Use extra sheet, if necessary): A. If your variance(s) Till an) of those hangeslbe negate a?r Please explanoyo~~ a~swerin detail. properties change. W Y ~ Vr ~nL,,riu ~ _ . r r _~_ r., 1. _.... _ L a h~~j~ B. Please explain why you need the variance(s). Is there any way to reach the same result without a variance(s)? Please be specific in your answer. C. How big is the change from the standards set out in the zoning law? Is the requested area variance(s) substantial? If not, please explain, in detail, why it is not substantial. ~ ~ c~ ` tz ~ L ,~ TOVd022.7_BA-AAV (4-03 Rev) 2 of 4 D. If your variance(s) is(are) granted, will the physical environmental conditions in the neighborhood or district be impacted? Please explain, in detail, why or why not. Town of Wappinger Zoning Board of Appeals Application for an Area Variance Appeal No~7; -7~ - 4. List of attachments (Check applicable information) Last Revised and ( ) Survey Dated Prepared by ( ) Plot Plan Dated ( ) Photos ( ) Drawings Dated Letter of Communication which resulted in application to the ZBA. () (e. g., recommendation from the Planning,8oard/Zoning Debated: °~ Letter from g~ ~ ~ ~~ Dated Letter from ( ) Other (please list): 5. Signature and Verification Please be advised that no application can be deemed complete unless signed below. The applicant hereby states that all information given is accurate as of the date of application. ~~~I~ DATED: Z`i ~ ~i3 SIGNATURE (Appellant) DATED: ~ ~~ SIGNATURE ellant (If re than one App ) TON'022."LB,4-AAV (~-U Rev) 3 of 4 F. Is your property unique in the neighborhood that is needs this type of variances riedSC C~N:~~~i E. How did your need for an area variance(s) come about? Is your difficulty self-created? Please _~_:.. .,,,~~r anc~nlPr in detail. ORICI.rvAG FOR OFFICE USE ONLY 1. THE REQUESTED VARIANCE(S) ( )WILL / (X) WILL NOT PRODUCE AN UNDESIRABLE CHANGE IN THE CHARACTER OF THE NEIGHBORHOOD. 2, ( ) yES / (~ NO, SUBSTANTIAL DETRIMENT WII.,L BE CREATED TO NEARBY PROPERTIES. 3. THERE ( ) IS (ARE) / (~ IS (ARE) NO OTHER FEASIBLE METHODS AVAILABLE FOR YOU TO PURSUE TO ACHIEVE THE BENEFIT YOU SEEK OTHER THAN THE REQUESTED VARIANCE(S). 4 THE REQUESTED AREA VARIANCE(S) (X) IS (ARE) / ( ) IS (ARE) NOT SUBSTANTIAL. 5. THE PROPOSED VARIANCE(S) ( )WILL / (X) WILL NOT HAVE AN ADVERSE EFFECT OR IMPACT ON THE PHYSICAL OR ENVIIZONMENTAL CONDITIONS IN THE NEIGHBORHOOD OR DISTRICT. 6. THE ALLEGED DIFFICULTY ( X} IS / ( ) IS NOT SELF-CREATED. CONCLUSION: THEREFORE, IT WAS DETERMINED THE REQUESTED VARIANCE IS (X} GRANTED ( }DENIED. CONDITIONS/STIPULATIONS: The following conditions and/or stipulations were adapted by resolution of the Board as part of the action stated above: The ZBA has granted a 12 foo variance for the construction of a 10 x 7foot 6 inch front deck. Where a 35 foot f~sont yard setback is required, the applicant can only provide 23 feet. ( )FINDINGS & FACTS ATTACHED. DATED: October 22, 2013 ZONING BOARD OF APPEALS TOWN OF WAPPINGER, NEW YORK BY: -~i~`~s~ Ac t i hair PRINT: ~ ~ PROJECT ID NUMBER - ~ '~ D PART 1 • PROJECT INFORMATION 1. APPLICANT /SPONSOR OSt.~ l/i + Ali a-.M /~'~'~ 3 PROJECT LOCATION: 617.20 APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only (To be completed by Applicant or Project Sponsor) 2. PROJECT NAME ~+ f ~ r`j) County ~ (/Li.-c- SJ Municipality 4. PRECISE LOCATION: Street Adders and Road intersections, Prominent landmarks etc - or provide map SEAR l `~ ~~,d.~ /U1.1 [ (moo ~ G'd~ M .' (r (~ h ~1,J~.~~Q ~' mil New ~ Expansion ~ Modification / alterat n 5. lS PROPOSED ACTION : L~J 6. DESCRIBE PROJECT BRIEFLY: ~/ , (' ,Q _' ~y r ~ ~ r hn,«ltirl~. b-y~.~ tl r"-~-~-µ-- TiL ~~ ~"~°"'' ~ /'' au-; . ~r ~ ~ '~ ~Y~ r 1^~ ~,,,,,,t~I,t.~~^ ~~- Sl~p~ ~ ,Sal-'` and ~c~~fi°~sG~ ~°~ ~ u~~~ n~ ~„~ , 7. AMOUNT OF LAND AFFECTED: Ultimately acres / !e qty Initially acres 8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS Yes © No If no, describe briefly: ~,,1 l l ( /Lr- ~ uwt,c i - ~ 9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) ^ Other describe) Residential ~ Industrial ~ Commercial ^Agriculture ~ Park /Forest! Open Space ( 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY (Federal, State or Local) Yes ~ No If yes, list agency name and permit /approval ~V6 I ~ ry , 11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL? Yes ®No If yes, list agency name and permit !approval: 12. AS A RESULT OF PROPED ACTION WILL EXISTING PERMIT I APPROVAL REQUIRE MODIFICATION? ^yes ^ No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE 6EST OF MY KNOWLEDGE Date: Applicant /Sponsor Name ,,/ //- ~ /~ ~/Z!~/~3 A/ //~ .f~ /I/LGiw~ /Y~/I /liar. r~v~-~.- _ If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment Town of Wappinger 20 Middlebush Rd. Wappingers Falls, NY 12590 (845) 297-6256 To: For Property Located at: Your application to: CONSTRUCTION OF FRONT DECK 10' X 7' 6" SBL: Date of This Notice: Zone: Application #: is denied for the following deficiency under Section 240-37 of the Zoning Laws of the Town of Wappinger Where 35 feet to the front property line is required, the applicant can only provide 2~ feet. ~3 "Accessory Structures must comply with all minimum yard setback requirements for buildings, but in no case ° shall they be permitted in the front yard." o Does NOT MEET dimensional requirement for Zone. o "This zoning district has a front yard requirement of seventy-five feet (75') from a state or County road." As per code Section 240-26, which states: "The use of tents, trailers and mobile homes for permanent o dwelling purposes shall not be permitted in any district except as permitted and regulated in Section 240-51, Mobile home park, of this chapter..." REQUIRED: WHAT YOU CAN PROVIDE: REAR YARD: SIDE YARD (LEFT): SIDE YARD (RIGHT): FRONT YARD: ~ SIDE YARD (LEFT): SIDE YARD (RIGHT): ft. ft. ~ft. ft. ~ft. ft. ft. ft. ~ft. ft. ft. ft. You have the right to appeal this decision to the Zoning Board of Appeals within 60 days of the date of this letter. The Zoning Board of Appeals meets the second and fourth Tuesday of the month. The area variance appeal will require at least two meetings, one for discussion and one for a Public Hearing. The required forms can be obtained at this office. Very truly, ~ ~~~ „fit ~ ~ ~, /, Barbara Roberti Zoning Administrator Town of Wappinger TOWN OF WAPPINGER BUILDING DEPARTMENT 20 Middlebush Road, Wappingers Falls, N.Y. 12590 telephone:845-297-6256 fax:845-297-0579 APPLICATION FOR BUILDING PERMIT APPLICATION TYPE: O Residential O New Construction O Commercial O Renovation/Alteration O Multiple Dwelling APPLICANT NA_NIE: ADDRESS: CELL: TEL #: ~/S - 2 ~~ °° i ~ ` ~ CELL: ~S' ~~~' Ss3 ~ FAX #: ~- E-MAIL: `on~yae./'P~. NAME OW1V"ER OF BUII-DING/LAND: <J~W ~L/Q f ^~~+~ ~t'~ c't, /J *PROJECT SITE ADDRESS*: ~~~ Ci0~2 ~' ~~l~~v MAILING ADDRESS: /~/ C~.oE~ 0 ''`f L~,~1 ~?~S~r3 l~~/S TEL #: Z9 ~' ~~'~ t~ CELL: -7 ~~"~ ~ ~ ~ FAX #: ----- E-MAIL: BUILDER/CONTRACTOR DOING WORK: COMPANY NAME: .~~~ ADDRESS: TEL #: DESIGN PROFESSIONAL NAivIE: TEL #: CELL: _ APPLICATION FOR: L ZONE: ~o~ DATE: -~G'/ APPL #: ~~ PERp1rII`T~#_ GRID: ~ o?Jr0'~ T- O•Z 7~ ~ _ 117/Lc: ~' FAX #: FAX #: 7~~~ c~F A b~'~k E-MAIL: E-MAIL: ~- - / n oy M(~~/i_l~ SETBACKS: FRONT: REA~/R: `~ L-SIDEYARD: R-SIDEYARD: SIZE OF STRUCTURE: ~} ~~ l~ ESTIMATED COST: ~+ 3 O ©U TYPE OF USE: E9y7'~' ~ ~ C~ NON-REFUNDABLE APPL. FEE:~~PAID ON:9 r6 3CHECK # C..a°'"- RECEIPT #:~, - S~a~S BALANCE DUE: PAID ON APPROVALS: ZONING ADMINIST OR: O Appro~d ~ D,. ~ied,.~at~ ~~` ~/ ature of Applicant tDE'Ia- CHECK # RECEIPT #: FII2E INSPECTOR: O Approved O Denied Date: Signature of Building Inspector i OWN ~F WAPPINGER oiaECr,oNS: ~~ ~ i- CFAW STP.UCTU RE TG BE kCDED 2- L:..B EL ;TS DII•I~NSIONS R-, +rs EUILDING FtRhA[T x_.._------ LOfAi1dN N 5 SiDE- E W HOUSE NUMBEr~~~ LOT NU OWNER OF INTERIOR R CC?Rh:ER LC7T Nearest Street _ ft. ~ , i i ~ i ` Mark North Fofnt ra 1, _~~. a c~ .~ ~ r LA5EL Sc. ~~r_K., 1.1.^. AR v1. i i, % ~ a{~ DATE C ~--- ~i ~_ ;4VENUE ~ /" ~~°~ ~~ `R .VOL. PAGE ~4'N7lCG.~ ZONE '~ DENIED ZC)f~ING ADMINIS~'~ 'a '~:)R P.car Yard ~+ P = ~ - ,~ ----~' J G~~CG'C ~.~C- ~ ! ,a~ ~. 6 Sidayard He i:~ E k. ~~ - y ~_~~- ~ ~ X: ~ ~~ r ~,s~,~ ~ ,l • ~ ~~ t ~ . , sit '~~"~;, r. ~ ~ . _ ~. ~ . ~~, ~: ~ ' ~ . ~.- J , ~ NPaiest Street it ~~y~--~ ~. d FteDIGAT"E L~JCAT[OIV of tN€~..LL and SEINAOE S1'STF~1 >ind THE DISTANCE o[ EC.~H FROi~i HOUSE r ~ ~, Inlormdtiare ~~ Suppliacl by ****PLEASE SHOW DISTANCE FROM NEW STRUCTURE TO BOTH SIDES OF PROPERTY AND EITHER REAR OR FRONT PROPERTY LINE, WHICHEVER APPLIES***** Affida~ it uh Ezemptic,n to Shoe- Specific Prauf of ~~'url:ers' Compensation Insurance Coy erabe fora 1, 2, 3 or ~ Family, O~~~ner-occupied Residence "Tlri.~ Juror c«rurur br used m nvri~~e the u~url,era' caulren.vuirur ri,lrts ur ubli~rriiun.~ uJrm_r/nrrt~."' t'nder penalty of perjur}', 1 ce~lify that 1 am the owner of the 1, 2, ~ or 4 family, u~~'ner-occupied residence (including condominiums) listed nn the buiiltdsurance,lcovera leaforasuchltresideneedblecause t(pl~asee~he;ckh he specific proof of ~~-oi hers' compensation a ~ pria ~ hoz): gun performing all the ~~'orl: for ~~'hich the building permit ~~~as issued. ,im not hirin~,. paying a' compensating in an}' ~~'ay, the individual(s) that is(are) pc;rformmg all the wcu~l: J L .. 1 for ~~'hich the building, permit `g'as issued or helping me perform such ~~'c~tk. 1 have a homeowners insurance policy that is currently in effect and covers the property listed on the attached building, penrtit AND am hiring or paying individuals a total of less than 40 hours per ~>,~eek (aggregate hours for all paid individuals on thejobsite) for ~>~~hich the building permit ~~~as issued. 1 also agree to either: • acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit if I need to hire or pay individuals a total of 40 hours or more per ~~'eel: (aggregate hours for all paid individuals on thejobsite) for work indicated on the building perm it, or if appropriate, file a CE- ?00 exemption form; OR ~ have the general contractor, performing the work on the 1, 2, 3 ~p4 fag ily, ° orvide aeCro 1e ate woof of (including condominiums) 1 fisted on the building permit that I am a 1 in for, p PP P P workers' compensation coverage or proof of exemption from that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the bui]ding permit if the project takes a total of 40 hours or more per week (aggregate hours for all paid individuals on the jobsite) for work indicated on the building permit. / i~~~ ~ /~! 2~~ 3 ~~ (Date Signed) -a (Signature ofHomeo`~rner) (Homeowner's Name Printed) Property Address that requires the building permit: /y~ Cep =~ ~~~~ ~Q.~p ~S --29~-/~0~ Home Telephone Number Sw--n ro efnre nre thi~C/ ~ da of --- - ' --'-=~f~-r,N--p ~ 1- -~ ,(county C c,' ~~M Yv~i.L~~M•~ i N Public, State of New { No. 01 WI5030858 ~ Residing in Orange Cou ~ ~ Commission Expires July 25, 0 i _. _ ._ . . Once notarizcrl, this t3P-1 form ser~~es as an exemption for both.+~arkers' compensation anti disability' bencirts insurance co~~erabe. NY-V~tCB Town of Wappinger 20 Middlebush Rd. To: For Property Located at: Your application to: CONSTRUCTION OF FRONT DECK 10' X 7' 6" is denied for the following deficiency under Section 240-37 of the Zoning Laws of the Town of Wappinger Where 35 feet to the front property line is required, the applicant can only provide n~ et. Wappingers Falls, NY (845) 297-6256 12590 SBL: Date of This Notice: Zone: Application #: "Accessory Structures must comply with all minimum yard setback requirements for buildings, but in no case ° shall they be permitted in the front yard. o Does NOT MEET dimensional requirement for Zone. o "This zoning district has a front yard requirement of seventy-five feet (75') from a state or County road." As per code Section 240-26, which states: "The use of tents, trailers and mobile homes for permanent o dwelling purposes shall not be permitted in any district except as permitted and regulated in Section 240-51, Mobile home park, of this chapter..." REQUIRED: REAR YARD: SIDE YARD (LEFT): SIDE YARD (RIGHT): FRONT YARD: SIDE YARD (LEFT): SIDE YARD (RIGHT): WHAT YOU CAN PROVIDE: ft. ft. ft. ~ ~ ft. ft. ft. ft. ft. ft. ~~ ft. ft. ft. You have the right to appeal this decision to t h Tuesda of theomonpth aThelarea vadriance appeal will requiretatrlea t two Wing Board of Appeals meets the second and fount Y meetings, one for discussion and one for a Public Hearing. The required forms can be obtained at this office. Very truly, j c--~ Barbara Roberti Zoning Administrator Town of Wappinger TO`VN OF WAPPINGER BUILDING DEPARTMENT 20 Middlebush Road, Wappingers Falls, N.Y. 12590 telephone:845-297-6256 fax:845-297-0579 AP PLICATION FOR BUILDING PERT APPLICATION TYPE: O Residential O New Construction O Commercial O Renovation/Alteration O Multiple Dwelling APPLICArT NAME: L ADDRESS: TEL #: ~lS' Z ~~ ~- ~o~Y CELL:~s ~GY- SS9~' FAX #: ~-- E-MAIL: NAME OWNER OF BUII,DING/LAND: ~.~W ~LQ ~~ , fir LL ~ *PROJECT SITE ADDRESS*: ~y~ CJO~z /~+ ~/ L~~~ / ~1AILING ADDRESS: `ya C~ar,C ~l~La~D ~~/°-~'~h~r~S ~~~5-~ TEL #: Z `~ ~' ~'~ `~ ~~ CELL: 7 ~~--5 s ~ ~ FAX #: ---- E-MAIL: BUILDER/CONTRACTORDOWG WORK, :/~ COMPANY NAiv1E: • ~~~ ~"°' ADDRESS: TEL #: CELL: DESIGN PROFESSIONAL NAME: TEL #: CELL: _ APPLICATION FOR: ZONE: ~o~ DATE• -~~e '~ APPL #:~zS~~ PERp!tiITT`/# GRID: ~ ~/ O'~ ~ O.Z 7~ FAX #: FAX #: r, rr a s ca~G A b ~c k E-MAIL: _ E-MAIL: vv - ~ ~ /y ~ ,~, SETBACKS: FRONT: REAR: L-SIDEYARD: ~1lr~'i SIZE OF STRUCTURE: IO, ~ / b ESTLI-SATED COST: ~ 3 O ~ a TYPE OF USE: R-SIDEYARD: ~,~v 7'~' A cJ CL~ p ~ a NON-REFiTN'D ABLE APPL. FEE:~~PAID ON:f (~O CHECK # RECEIPT #:~ - Spa S BALANCE DUE: PAID ON APPROVALS: ZONL~IG ADVIINIST OR: / / O Approved ~ D,enied JD ate: ~ ~~='~/ "~ ~ ./ =! Lure of Applicant CHECK # RECEIPT #: FIlZE P1 i SPECTOR: O Approved O Denied Date: Signature of Building Inspector ;OWN C)F ':~APPiI~iGEi`Z SIP r-r,oNs: - D~.w sTRU~~ua. rc a= ~:coao ~~° ~ ~~ ~ Z- L?.B EL IT. DIi~1=NS10N5 7 - ngE' c-91,_KS 1^A-H FP.R01^.'S BUILDING l/~RMUT x------- LOCATIGN N S SiDF-~ E W HOUSE NU~BER~~ -LOT t~U c' OWNER OF INTERIOR R CQRPdER LOT-r Pear Yard 5.3 ~ ~ d ------ c s i /:i C ATE ~ i -- ~strc ~Cn17/L~.,4 DENIES ZpPSiN~ ADMiiVIS~' .-~€t irk } h: --, I, ~ ~~ LPG 1 ~-.GCS"/ l s:d~y std {t .~ ~ t ~ , -f- ~~ r r ~ . r ~ f ~- s~ ask ~ = +~ ` y _ ~ ~;~,~ Neatest Street ~ ~° ~--~ ~~ Neaten Sfre^_t _ ft. fronte~~ -.- -.----~. ~a ff. d ~, ---- I"t~t~bGA';•"E L~JC.~T[ON at ~'i':LL End SE1?~'1RGE SYSTF111 srd THc_ D[STA?`ICF o[ Et-~H FRC7A+1 HOUSE , , ~; ~ _ r Inforndtien ~ `~ ~~ ~ ~>~ ~`, Suppl:ed by Mark Nor1Ft Fofnt PAGE ZONE **PLEASE SHOW DISTANCE FROM NEW STRUCTURE TO BOTH SIDES OF PROPERTY AND EITHER REAR OR FRONT PROFERTY LINE, WHICHEVER APPLIES''**" ~= ,~ffida` it ui' Elemptian to Shoe- Specific Pruuf of ~n`~'-o~ccu ~ edl,R snden~ce InSUrance Coy erase fora 1, 2, 3 or -~ Family, O I - °Thi.~ Jiirrrr cururor be trserl rn u~uire rke mr~rl,cr.r' nrurlrensuliun ri~lrl.~ ur uLli~u~iurrs uJur~rhur(I." t'nder Penalt} of Perjury, I cel-tif) that 1 am the awner of the ]. 2, ~ or 4 family, u`~'ner-occupied residence (including condominiums] listed an the builhdsurancellcove a leaforalsuchllresidencedbecause 1(pl~alseG~htec.kf,the specific proof of warl;ers' compensation a ~ prr<i - has j: ~ I am performinG all the ~~~url: for ~~~hich the building permit ~~~as issued. ~i nat hiring. ~ayuig UI' CalllpenSallnS Ill any ~~'ay, the individual(s) that is(are) performing all the ~~~cu~l: ] ~I i ~ 1 for ~~rhich the building permit `a~as issued or helping me perform such ~>`rc>Ik. 1 have a homeowners insurance policy that is currently in effect and covers the property listed on the attached building permit AND am hiring ar paying individuals a total of less than 40 hours per ~>,rc;ek (aggregate hours for all paid individuals on the jobsite) for which the bu ildin~ permit ~~~as issued. I also agree to either: • acquire appropriate workers' compensation coverage and provide appropriate proof of that coverage on forms approved by the Chair of the N1'S Workers' Compensation Board to the governmen QU~'e~ate holurs the building permit if I need to hire or pay individuals a total of 40 hours or more per «eel: (a~~ b for all paid individuals on thejobsite) for work indicated on the building permit, or if appropriate, file a CE- 300 exemption form; OR • have the general contractor, performing the work on the I, 2, 3 or 4 family, owner-occupied residence (including condominiums) listed on the building permit that I am appl)ring fot-, provide appropriate proof of workers' compensation coverage or proof of exemption from that coverage on forms approved by the Chair of the NYS Workers' Compensation Board to the government entity issuing the building permit if the project takes a total of 40 hours or more per week (aggregate hours for all paid individuals on the jobsite) for ~rork indicated on the building permit. ''~ '~ Date Signed) -~ (Signature of Homeo~~-ner) ( ~S C+.IAG~ ~~~J l ~G L A (Homeowner's Name Printed) Property Address that requires the Liuilding permit: ~s "-2~6 - /o~ ~ Home Telephone Numt~er 5xprn [o efore 1~re this _~/ ~~.da nJ y C,[er NoR~y Public, State of New Y'a fry' No. Ot WI5030858 Residing in 0 es Ju C25,~~0.~ Commission Exp Y ----_® Once notarized, this BP-I form ser~~es as an exemption for both wori:ers' compensation anti ciisabiiit~ benefits insurance co`~erabe. BP-1 (12/OS) NY-V,'CB