Section VII - AFFIDAVIT OF OWNERSHIP:( To be completed by Applicant and notarized )
STATE OF NEW YORK
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COUNTY OF WESTCHESTER
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(PRINT NAME) (OWNER, LESSEE, ARCHITECT, BUILDER, CONTRACTOR)
being duly sworn, disposes and says: that
(PRINT NAME OF PRODERTY OWNER)
is the owner of the premises to which this application applies; that he/she (the applicant) is duly authorized to make this application; and that the
statements contained here are true to the best of his/her knowledge and belief, and that the work will be performed in the manner set forth in the application and
in the plans and specifications filed therewith, and in accordance with all applicable laws, ordinances and regulations.
Signature of Applicant/Contractor
Westchester County License#( if applicable)
Applicant Sworn Before Me This
Day of
20
NOTARY PUBLIC
(NOTE: The filing of this application does not constitute a permit to commence construction)
Section VIII - BUILDING OWNER CERTIFICATION (If applicable):( To be signed by Owner)
I, , hereby certify that i have full knowledge of the proposed alteration at my property as
described herein and take no exception to such activity.
Signature of Property Owner Date
Note: A notarized letter granting the above signed applicant permission to submit this application can be attached to application , in lieu of completeing owner certification.
Print Name & Title.
Section IX - BUILDER / CONTRACTOR CERTIFICATION:( To be signed by Builder or Contractor and witnessed )
I, , the Builder/Contractor, to the fullest extent permitted by law, shall save, keep , indemnify
and hold harmless the City of White Plains and their respective officers, officials, employees, and agents from and against all liability,
injury, loss or damage, cost or expense in law or in equity that may at any time arise directly or indirectly by reason of or in the course of
performing the work pursuant to the Building Permit, which may be occasioned by any willful or negligent act or omission of the permitee,
any of the permitee's employees, volunteers or any subcontractor. The foregoing provisions shall not be construed to cause the permitee to
indemnify the City of White Plains from it's sole negligence. The Builder/Contractor hereby agrees to perform said work strictly in
accordance with the conditions of the permit, the provisions of the Charter and the Ordinances of fhe City of White Plains , and the rules,
regulations, and specifications of the Department of Building.
Signature of Builder/Contractor Date Westchester County License # Signature of Witness Date
Name of Company or D/B/A
Print Name of Witness
Section IX - ARCHITECT/ENGINEER CERTIFICATION (If applicable):
I, , hereby certify that the plan (s) submitted herein were prepared under my supervision and to the
best of my knowledge are in compliance with the applicable provisions of the International Building Codes, Codes of New York, including
the White Plains Supplemental Code.
Signature of Architect/Engineer Date Signature of Witness Date
Print Name & Title.
Print Name of Witness
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