Affidavit of Equipment of Detectors

Telephone (845) 429-2200

TOWN OF HAVERSTRA W

BUILDING DEPART MENT

ONE ROSMAN ROAD

GARNERVILLE, NEW YORK, 10923

Fax: (845) 786-7647

AFFIDAVIT

SMOKE DETECTOR & CARBON MONOXIDE

STATE OF NEW YORK )

COUNTY OF ROCKLAND )

I ____________________________________________________________________________being duly sworn,

deposes and says:

1. That I currently reside at:___________________________________________

___________________ ______________________ ______________________ _____

2. That the premises at: ________________________________________________

____________________________________________________________________

New York, is presently equipped with a smoke detector and a carbon monoxide detector

located adjacent to the bedrooms and that these systems are presently in good working

order.

That this Affidavit is being given with the knowledge that it will be relied upon by the

Town of Have rs tr aw in o rd er to appr ov e a Certificate of Occupancy and A Violation

Search for these premises.

Tax Designation: Section;_________________ Block:___________ Lot:_____

___________________________

Signature

Sworn to before me this ____ day of ____________, 20 ___

__________________________________

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