AFFIDAVIT OF COST*
STATE OF NEW YORK }
COUNTY OF WESTCHESTER } ss:
, being duly sworn, deposes and says : the actual cost , to him/her , for work
(OWNER, TENANT-LEASEHOLDER)
which permit No.
was issued to Contractor(s):
at the premises known as SBL:
and Street No.
to be the sum of (ACTUAL COST FOR ADDITION)
(ACTUAL COST FOR ALTERATION)
(ACTUAL COST FOR NEW BUILDING)
*COST-The term "Cost" means the actual value of all services, labor materials, construction,equipment, rental and
service equipment installations; but not including cost of such grading,decorating or other intended primarily for
appearance or embellishment and which is not necessary for the safe and lawful use of the building or structure
(such as carpeting and furniture).
Signature of Owner, Tenant or (Leaseholder)
day of
,
NOTARY PUBLIC
DO NOT FILL IN BELOW THIS LINE:
------------------------------------------------------------------------------------------------------------------------------------------------
AMOUNT PAID $
BALANCE DUE $ Permit No.
REFUND $
RECEIPT# $
DATE PAID:
70 Church Street, White Plains, New York 10601
Phone: (914) 422 - 1269 * Fax: (914) 422 - 1471
DEPARTMENT OF BUILDING
CITY OF WHITE PLAINS
AFFIDAVIT OF COST 03/13
http://www.cityofwhiteplains.com
$
$
$
Sworn to before me this
TOTAL FEE DUE $
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