Application For Grading Permit Form - Town Of Lagrange
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1TOWN OF LAGRANGE
APPLICATION FOR GRADING PERMIT
IDENTIFICATION OF APPLICANT
NAME OF OWNER ______________________________________________________________________
PHONE ______________________
NAME OF CONTRACTOR ________________________________________________________________________________________________
911 ADDRESS ___________________________________________________________________________________________________________
PARCEL GRID NO. ____________________ SUBDIVISION NAME _______________________________ SUB. LOT NO. _______________
APPLICANT'S NAME (If other than owner)___________________________________________________________________________________
DESCRIPTION OF WORK TO BE PERFORMED
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RESIDENTIAL
COMMERCIAL
OTHER
DESCRIBE PROPOSED WORK: ___________________________________________________________________________________________
_______________________________________________________________________________
TOTAL AREA OF DISTURBANCE
ATTACHED HERETO & MADE A PART OF THIS APPLICATION I SUBMIT THE FOLLOWING DOCUMENTS:
(Please check appropriate boxes)
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A PROPERTY SURVEY OR A COPY OF THE APPROVED PLOT OF THE AFFECTED PREMISES
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GRADING PLAN
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DRAINAGE EASEMENT TERMS (AS FILED WITH THE DEED)
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EROSION AND SEDIMENT CONTROL PLAN WITH DETAILS & SPECIFICATIONS FOR SITE STABILIZATION
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LANDSCAPE PLAN AND SPECIFICATIONS FOR FINAL SITE STABILIZATION
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WETLANDS PERMIT WHEN WORK AREA IS WITHIN A REGULATED AREA
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NYS DEC SPDES GENERAL CONSTRUCTION PERMIT GP-02-01 PROOF OF COVERAGE
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TOWN DRIVEWAY PERMIT
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DOT/DPW WORK PERMIT
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PROOF OF WORKMAN’S COMPENSATION INSURANCE ON FORM#C-105.2 OR U26.3 BY THE CARRIER
APPLICATION IS HEREBY MADE TO THE OFFICE OF THE BUILDING INSPECTOR, DEPARTMENT OF PLANNING, ZONING, AND BUILDING PURSUANT
TO THE CODE OF THE TOWN OF LAGRANGE AS ADOPTED BY THE TOWN BOARD. THE APPLICANT AGREES TO COMPLY WITH ALL APPLICABLE
LAWS, ORDINANCES & REGULATIONS.
___________________________________________________
_____________
DATE
SIGNATURE OF APPLICANT
(Must be signed in office)
OFFICE USE ONLY
RECEIPT OF PAYMENT $ 100.00
DATE _______________
RECEIPT NO. ___________________
APPROVED __________________________________________________________________________________
DATE __________________
(
Administrator of Public Works)
(ADD ANY COMMENTS ON BACK)
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