Fillable Printable Affidavit of Ownership - New York

Affidavit of Ownership - New York

NYC Department of Transportation

Bureau of Permit Management and Construction Control

55 Water Street, New York, NY 10041

www.nyc.gov/dot

AFFIDAVIT OF OWNERSHIP

This form must be printed out. Type or print clearly. Mail to:

New York City Department of Transportation

Permit Management & Construction Control

Permit by Mail

55 Water Street, Concourse Level

New York, NY 10041

STATE OF NEW YORK

COUNTY OF:_______________________________________________________________

I, _________________________________________, being duly sworn, depose and say the

following:

1. I am the owner of premises_______________________________________________

in the Borough of _______________________________________________________

2. I personally will perform the repairs to the sidewalk of the said premises.

3. I am aware that the law requires that if the said repairs are to be made by any person other

than myself, the required Workers Compensation Insurance, and Commercial General Liability

Insurance policy must be filed with the Department of Transportation.

_____________________________________

(Signature of Owner)

State of New York, County of ____________________________On the ________________ of

________________, before me personally came ______________________________________ to

me known to be the individual described in and who executed the forgoing instrument, and

acknowledged that _________________________________________________________________

executed the same.

___________________________

Notary Public