70 Church Street, White Plains, New York 10601
Phone: (914) 422 - 1269 * Fax: (914) 422 - 1471
DEPARTMENT OF BUILDING
CITY OF WHITE PLAINS
Designer's Affidavit for Plans 03/14
http://www.cityofwhiteplains.com
DESIGNER'S AFFIDAVIT FOR APPROVAL OF PLANS AND SPECIFICATIONS:
This application must be printed or typewritten and sworn to by applicant.
To: Commissioner of Building Subject: Building Permit Application#
Address: SBL:
Work Description:
Application is hereby made for approvals of the plans and specifications herewith submitted and to be made a part thereof for the structure
herein described, with the understanding that:
1. If this application shall be disapproved in part and if no further action is taken thereon within six months after notice of partial
disapproval , it shall be automatically withdrawn.
2. Any permit issued under which no work is commenced within six month form the time of issuance shall expire by limitation.
3. Work will be will not be (select applicable) supervised by a Registered Architect or Professional Engineer.
4. Work will not be commenced until a permit has been obtained, application for which will be filed with the Commissioner of
Building accompanied by satisfactory evidence that insurance requirements have veens satisfied, and payment of the prescribed fee.
STATE OF NEW YORK }
COUNTY OF }
(PRINT NAME) ARCHITECT / PROFESSIONAL ENGINEER
being duly sworn, deposed and says: that he /she resides at
( ARCHITECTURAL, STRUCTURAL , MECHANICAL)
Applicant Sworn Before Me This
Day of 20
NOTARY PUBLIC
in the City of , in the County of , in the State of ,
that he/she is making this application for the approval of plans specifications herewith submitted and make part hereof , for the building therein described. Deponent
further says that he /she has personally supervised the preparation of the plans and that to the best of his
knowledge and belief, the work will be carried out in compliance therewith, and the structure, if built in accordance with such plans, will conform with all the
provisions for all other laws and regulations applicable thereto in effect on this date. Deponent further says that he is duly authorized by
who is the Owner in fee or Lessee of all the certain, piece or parcel of land shown on the diagram annexed hereto and made a part hereof, to make application for the
approval of such detailed statements of specifications and plans, elevations ( if any) and amendments hereto, in the behalf.
Deponent further says that the full names and residences, streets and number, of the owners of the said land, and also every person interested in said building or
proposed structure are as follows: OWNER: ADDRESS:
( If Corporation give name &
address of at least two officers ) OWNER: ADDRESS:
LESSEE: ADDRESS:
(OWNER'S OR LESSEE'S)
( LICENSED NYS DESIGN PROFESSIONAL )
Sworn to before me, this _______day of _____________ , _______ .
AFFIX SEAL OF REGISTERED ARCHITECT OR PROFESSIONAL ENGINEER
NOTARY SEAL
