CERTIFICATION IN LIEU OF OATH
I. OWNER SECTION (to be completed if the applicant is the owner in fee)
I hereby certify that I am the owner in fee of the property listed on Page 1.
Mark the following applicable boxes:
A. ( ) I further certify that a new home (private residence) will be constructed on this property for my own use and occu-
pancy. This dwelling is to be occupied by myself and is not to be used for any purpose other than single family
residential use. I attest that all construction, plumbing, or electrical work will be done, in whole or in part, by me or by
subcontractors under my supervision, in accordance with all applicable laws; and, I further acknowledge that said
new home is not covered under the New Home Warranty and Builders Registration Act (N.J.S.A. 46:3B-1 et seq.) and
that such fact shall be disclosed to any person purchasing this property within ten years of the date of issuance of a
certificate of occupancy.
I UNDERSTAND THAT IN MARKING BOX A, I ACKNOWLEDGE THAT I AM ASSUMING RESPONSIBILITY FOR
THE WORK DONE ON SAID PROPERTY, THE CONDITION OF THE PROPERTY PRIOR TO, DURING, AND AFTER
ANY WORK PERFORMED, AND FOR THE PERFORMANCE OF THE SUBCONTRACTORS I HIRE, EMPLOY, OR
OTHERWISE CONTRACT OR WITH WHOM I MAKE AGREEMENTS TO PERFORM WORK. I AM VOLUNTARILY
AND KNOWINGLY ASSUMING THIS RESPONSIBILITY.
B. ( ) I further certify the following as required by the New Jersey Uniform Construction Code, N.J.A.C. 5:23-2.15(f)1.ix:
I personally prepared the plans submitted for: 1) the new home referred to in A.; or, 2) an addition, alteration, renova-
tion, or repair to an existing single family residence owned and occupied by myself and located on the property listed
on Page 1; or, 3) a new structure that will be physically separate from, but that will be deemed part of, an existing
single family residence that is owned and occupied by myself and located on the property listed on Page 1.
C. ( ) I further certify that I will perform or supervise the following work:
C.1. ( ) Building C.2. ( ) Fire Protection
I further certify that I will perform the following work:
C.3. ( ) Electrical C.4. ( ) Plumbing
D. ( ) I agree to advise all contractors on this project that they are required to be registered with the New Jersey Division of
Taxation and to comply with all New Jersey tax laws.
I further certify the following as required by the Uniform Construction Code, N.J.A.C. 5:23-2.15(a)5: All required State, county,
and local prior approvals have been given, including such certification as the construction official may require.
I understand that if any of the above statements are willfully false, I am subject to punishment.
Signature_____________________________________________________________ Date _______________________
II. AGENT SECTION (to be completed if the applicant is not the owner in fee)
I hereby certify the following as required by the Uniform Construction Code, N.J.A.C. 5:23-2.15(d): the proposed work is autho-
rized by the owner in fee; and I have been authorized by the owner in fee to make this application as his agent.
I further certify the following as required by the Uniform Construction Code, N.J.A.C. 5:23-2.15(a)5: All required State, county,
and local prior approvals have been given, including such certification as the construction official may require.
I agree to advise all contractors on this project that they are required to be registered with the New Jersey Division of Taxation
and to comply with all New Jersey tax laws.
I understand that if any of the above statements are willfully false, I am subject to punishment.
( ) Check if contractor.
Agent Name _________________________________________________________________________________________
Address _____________________________________________________________________________________________
___________________________________________________________________________________________________
Telephone ___________________________
Signature____________________________________________________________________________________________
III. ( ) LEAD HAZARD ABATEMENT: Include Homeowner or Building Owner Affidavit as per N.J.A.C. 5:17.
U.C.C. F100-2 (rev. 5/2007)
