Fillable Homeowner Affidavit Building DivisionALL Forms 4-17.indd (City of Grove City)

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Homeowner Affidavit Building DivisionALL Forms 4-17.indd (City of Grove City)

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Grove City Building Division
4035 Broadway
Grove City, OH 43123
614-277-3075 (Phone)
614-277-3090 (Fax)
GroveCityOhio.gov
HOMEOWNER AFFIDAVIT
________________________________________ , I do certify that I am, or will be, the occupying homeowner of a single family residence
and hereby submit application to undertake the following work located at:
Address _____________________________________________________________________ Phone ___________________________________
REQUIRED PERMIT
Type _________________________________________________________________________ Fee: $ ___________________________________
I live in this residence with my family.
I will move into this residence with my own family for a minimum of six months after the proper occupancy permit has been issued.
I agree to only use this dwelling as the home for my family and me.
I will not enter into a contract with an unregistered contractor and I will do the work as required by the respective codes. It is un-
derstood that I may have the assistance from other persons not registered as contractors with the City of Grove City providing no
contract either verbal or written exists among the parties involved.
The permit application and the proper fee are attached. The work being completed by someone other than me, requires permits by
registered contractors. No construction will commence until proof of proper fi lings is made.
I HAVE TOLD THE TRUTH ON THIS AFFIDAVIT AND ON THE ATTACHED PERMITS.
Falsifi cation of a public document is a violation of the Ohio Revised Code, section 2921.13(a)(3), a misdemeanor of the fi rst degree,
punishable by up to six months imprisonment and a fi ne of one thousand dollars ($1,000.00) or both.
Approved ____________ Denied _______________ Date: ____________
Comments _____________________________________________________________________________________________________________
NOTARIZED SIGNATURE
Signature of applicant ___________________________________________________________ Date __________________________________
Sworn to before me and subscribed in my presence this ______________day of _________________________, in the year ____________.
Notary Public _________________________________________________________ My commission expires ___________________________
NOTARY SEAL HERE
Revised 3/2017
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Homeowner Affidavit Building DivisionALL Forms 4-17.indd (City of Grove City)

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Completed 15 July 2020

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