TOWN OF JERUSALEM, NEW YORK Office:
Department of Code Enforcement and Administration Date Received:
3816 Italy Hill Rd. Tax Map #:
Jerusalem, New York 14418 Fee: $ Paid ☐
Telephone No.: (315) 595-2284 BP: #
Fax No.: (315) 305-3507 Approved ☐ Denied ☐
Email: ceo@jerusalem-ny.org
Website: www.jerusalem-ny.org
BUILDING PERMIT APPLICATION
1. Nature of work:
(Check all that apply)
☐New Build ☐Addition ☐Repair ☐Renovation ☐Alteration ☐Change of Occ.
☐Demolition ☐Roofing ☐Electrical ☐Plumbing ☐Generator ☐Other
2. Description of work:
3. Square Footage:
1st Floor: 2nd Floor: 3rd Floor: Basement: Total:
4. Estimated cost of work: $
5. Project Information:
(Type or clearly print)
Address of Project:
Property Owner:
Mailing Address:
Phone Number: Email:
Applicant Name:
Mailing Address:
Phone Number: Email:
Applicant is:
☐Owner ☐Agent ☐Architect ☐Builder ☐Contractor
Contractor Name:
Address:
Phone Number: Email:
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5. Project Information Cont.:
(Type or clearly print)
Architect Name:
Phone Number: Email:
Occupancy Classification:
Change of Occupancy? ☐Yes ☐No
State intended use and occupancy after proposed construction:
6. Required Documentation:
(If applicable)
☐ Proof of Workers Compensation and Disability Benefits Insurance Coverage. Acceptable Proof:
Certificate of Worker’s Compensation (form C-105-2 or U26.3) AND Disability & Paid Family Leave (Form
DB-120.10) OR Certificate of Attestation of Exemption (form CE-200)
☐ Plot Plan – A dimensioned plan to scale, indicating the shape, size, height and location in exact relation to
all property lines and to street or road lines of all buildings or structures to be erected, altered or moved and
of any building or structure already on the lot. A current survey may be required.
☐ Approved Set of Building Plans – Any plans for a home, an addition over 1500 sq. ft. and all commercial
buildings require a stamp and certification by a NYS Licensed Engineer or Architect. Any addition costing
more than $20,000 also require stamped and certified plans by a NYS Licensed Engineer or Architect.
☐ Waste Water Plans – Municipal Sewer Hook-up Permit ☐ , Septic Construction Permit ☐, or Review of
Existing System ☐
7. Affirmation: All information supplied in this application is true to the best of my knowledge and
belief. I understand and agree that all work will conform to all applicable local and state code
requirements. Permission is hereby granted to the Code Enforcement Officer to enter the premises
as frequently as reasonably necessary to inspect the project for compliance with the submitted
plans, the Uniform Code and the Municipal Code of the Town of Jerusalem.
Applicants Signature: Date:
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NOTE:
Upon issuance of a building permit, work may proceed as set forth in the specifications, plans or statements as
filed with the Code Enforcement Officer. Any Amendments made to the original plans and specifications must first
be submitted for approval. Building permits are good for one (1) year. Failure to complete and have all phases of
the project inspected within the one (1) year will require renewal along with fees and insurances.
Inspections are noted on the building permit and it is the responsibility of the property owner or contractor to call
this office to arrange. Twenty-four hour (one business day) advance notice shall be given. If work that needs to be
inspected is covered before the inspector can verify it, the work will have to be exposed to facilitate inspection at
the owner’s or contractor’s expense.
As a result of the issuance of the Building Permit, the Town Assessor is notified. The assessor will visit the site
periodically during construction to judge the percent of completion. This completed percentage is added to the roll
annually, and the Owner of Record will be notified of any change each year until the project is judged complete.
A Certificate of Compliance or Occupancy cannot be issued unless the required inspections have been made.
Without a Certificate of Occupancy the construction cannot be legally occupied. It is the owner’s responsibility to
adhere to all code compliance requirements and setbacks.
All new work is to be done in conformance with the provisions of the New York State Uniform Fire Prevention and
Building Code. Please be advised that failure to comply with applicable regulations and/or conditions of the permit
or should hazardous or unsafe conditions develop, we reserve the right to stop work.
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