250 Broadway, 29th Floor New York, NY 10007 212-386-0009 - Phone 646-500-6271 - Fax www.nyc.gov/bsa Margery Perlmutter Chair/Commissioner FORM FOR OBJECTION OR CONSENT The NYC Board of Board of Standards and Appeals has scheduled a public hearing on the following application: Address: Applicant: Please complete the Affidavit provided below and indicate whether you consent or object to the application. Name: _________________________________________________ I am the owner of or lessee at the following: Address: _______________________ _______________________ _______________________ ___ ___ I support the application I object to the application for the following reasons (attach additional paper if necessary) _________________________________________ _________________________________________ _________________________________________ _________________________________________ ____________________________ Sign Here Sworn to before me this _____ day Of _________________ 2_______ ____________________________ (Notary Public) American LegalNet, Inc. www.FormsWorkFlow.com