One Family Dwelling With Senior Residence

Filing Instructions

Instructions for filing a building permit application to use a one family dwelling for a senior residence use:

  1. A completed Building Permit application form. Application forms shall be filled out in their entirety and shall be signed by the property owner NOT the lessee. All information must be typed or printed. Cross outs will void out application.
  2. Three (3) copies of a complete (unaltered) survey by a licensed land surveyor.
  3. Two photostats of a plot plan, which shall indicate all existing and proposed buildings and structures as well as the proposed parking, required for all cars as listed on the Supplementary Statement.
  4. Two sets of complete floor plans, which shall include ALL floors, room uses, doors and stairs. The floor plans submitted shall also indicate Primary and Secondary Kitchen Units and fixtures.  If construction or alteration is required or proposed, a separate application shall be filed in accordance with the instructions for filing “for alterations and structures of minor character.” A non-structural plan will also be required for each set of floor plans showing how the dwelling is to be reverted back to a single dwelling unit after the use has ceased.
  5. One (1) photostat of a recent tax bill, showing Section, Block, Lot(s) and owners name and address.
  6. Sworn affidavits signed by the owner: Affidavit of Property Owner, Affidavit of Tennant / Lessee, and Consent for Inspection
  7. Copy of documentary proof of age (i.e. driver’s license, birth certificate, etc.)
  8. Declaration of Restrictive Covenants. (Must be filled out in black ink)
  9. A recent Building Department Record Search showing all building permit / application numbers for subject parcel. (A fee of $25.00 to The Town of Hempstead is required for this document)
  10. A recent PSEG or National Grid bill, which includes the owner's name and address.
  11. A copy of the deed.
  12. A minimum of four photographs that depict each side of the dwelling in its entirety.  Photographs shall be taken during the daylight hours and shall clearly depict the electric meter of the house.
  13. A Tax Map Verification letter required by Nassau County Department of Assessment. This document is available upon request by visiting  and selecting Tax Map Verification.  There is a $355.00 fee associated with this letter.
  14. Building Permit Filing Fee of $150.00, payable at time of application.  An additional $50.00 certificate of completion fee is payable at time of permit issuance. A document scanning fee of $35.00 may also be assessed upon issuance of the building permit.

Once you are notified that your application has been approved, it is required that you send in a blank check made payable to “Nassau County Clerk” for the filing of the Restrictive Covenants, and must be filled out in BLACK INK. Under the memo portion please note, “not to exceed five hundred dollars.” Submit this to the building department, along with the original, completed declaration of restrictive covenants.

A Plumbing Permit is required to install or maintain the secondary kitchen fixtures.


***At least one (1) of the two (2) separate dwelling areas authorized by a senior residence permit shall not exceed eight hundred (800) square feet in total floor space or a variance grant will be required from the Board of Zoning Appeals.

NOTE:  It is the policy of this Department to abandon and destroy, without notification, any application that has been left dormant by the owner or agent thereof for ninety (90) days.  All fees paid in relation to such an application will be non-refundable and non-transferable.  Applications and/or supplementary statements that are illegible, or that contain erasures or scratched out words will not be accepted.  The application and supplementary statements are sworn statements.  Anyone knowingly entering false information thereon may be guilty of a criminal offense.


Page Modified: 09/10/2020 16:28:07