OWNER'S AFFIDAVIT FOR PROVISION OF CONSTRUCTION FIELD INSPECTION BY LICENSED NEW YORK STATE
DESIGN PROFESSIONAL: This application must be printed or typewritten and sworn to by applicant.
To: Commissioner of Building Building Permit Application: Building Permit:
Address: SBL:
Work Description:
COUNTY OF }
STATE OF NEW YORK }
(PRINT NAME OF OWNER OR OFFICER OF CORPORATION)
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 or the Corportaion he/she represents is the Owner in fee of the premises to which this building permit applies; that he/she is fully aware of the provisions
of Section WPBCAE (gg) of the White Plains Supplemental Building Code and the New York State Building Code requiring that he/she engage the services of a New
York State Licensed Professional Engineer or registered Architect to provide for regular and periodic inspections of all construction work to be performed under the
above referenced Building Permit; that he/she has as of the date of this affidavit already engaged and authorized for the full duration of of construction the services
of a Licensed Professional Engineer(s) or Registered Architect(s) as designated below , in aaccordance with Section WPBCAE(gg) and all other applicable Sections of
the Building Code of the State of New York and the City of White Plains Supplemental Building Code.
DESIGNATED INSPECTION ENGINEER(S) / ARCHITECT(S) ACKNOWLEDGEMENT OF THE ABOVE AND OF REQUIREMENT TO
FILE ARCHITECT/ENGINEER'S AFFIDAVIT FOR FINAL INSSPECTION, UPON COMPLETION OF CONSTRUCTION:
ARCHITECTURAL STRUCTURAL MECHANICAL
SIGNATURE
PRINT NAME
ADDRESS
N.Y. LICENSE#
PHONE #
(SIGNATURE OF OWNER /OFFICER OF CORPORATION)
(PRINT NAME OF OWNER /OFFICER WITH TITLE)
(CORPORATION NAME & ADDRESS)
(PRINT ADDRESS OF OWNER OR OFFICER )
SWORN TO BEFORE ME THIS ____DAY OF ________20__.
( NOTARY PUBLIC)
70 Church Street, White Plains, New York 10601
Phone: (914) 422 - 1269 * Fax: (914) 422 - 1471
DEPARTMENT OF BUILDING
CITY OF WHITE PLAINS
Owner's Affidavit for Construction Inspe ction by Design Professional 04/13
http://www.cityofwhiteplains.com/
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