70 Church, White Plains, New York 10601
Phone: (914) 422 - 1269 * Fax: (914) 422 - 1471
DEPARTMENT OF BUILDING
CITY OF WHITE PLAINS
Owner's Certification of Inspection & Chimney cleaining. 04/13
OWNER'S CERTIFICATION OF INSPECTION & CHIMNEY CLEANING: This application must be notarized by applicant.
To: Commissioner of Building Boiler Permit : HVAC Permit:
Site Address: SBL:
COUNTY OF }
STATE OF NEW YORK }
(PRINT NAME OF OWNER)
being duly sworn, disposes and says: that he /she resides at
in the City of in the County of in the State of
that he/she is the Owner of the above stated site address , and understands the Chimney must be cleaned and inspected prior to initial startup. This is to certify that
the chimney flue has been completely cleaned ( wire brushed and deposits removed) and inspected, from roof outlet to base of chimney, including clean-outs and
vent connect. I further acknowledge that if chimney is condemned at time of cleaning, then a separate Mechanical permit shall be filed for a chimney liner.
SWORN TO BEFORE ME THIS ____DAY OF ________20__.
( NOTARY PUBLIC) (SIGNATURE OF OWNER)
(PRINT NAME OF OWNER )