TOWN OF BROOKHAVEN
BUILDING DIVISION
AFFIDAVIT FOR QUALITY OF STRUCTURAL STEEL FOR CERTIFICATE OF OCCUPANCY
STATE OF NEW YORK }
SS.:
COUNTY OF SUFFOLK }
, being duly sworn, deposes and says that he is the
of a corporation with
(title) (corporate name)
offices at
. That is
(address of corporation) (name of corporation)
engaged as the structural designer of structural steel for the building , and is the consultant for
and has designed, furnished, fabricated and erected
(general contractor owner)
structural steel for a
to be located at
(description of job)
according to the plans and specifications of:
(address of job)
(Name of Architect) (Name of Engineer)
That deponent affirms all the structural steel required for this work meets the standard specifications of A I S C and
ASD as required by the New York State Uniform Fire Prevention and Building Code.
I hereby certify under penalty of perjury that I am acting on my own behalf and that the foregoing statements are true
and correct to the best of my knowledge and belief.
(Signature of Affiant)
Personally appeared before me the above named
personally known to me,
who being duly sworn, deposes and says that he/she executed the above instrument and that the statement and answers
contained therein are true and correct to the best of his/her knowledge and belief.
Subscribed and sworn to before me this
day of ,20________.
(Notary Public)
TAX MAP NUMBER: __________________________________________________________________________________________________
8/2011
