New York City Department of City Planning Land Use Review Application Supplemental Form Special Permit/Authorization/Certification. . . .ZS/ZA/ZC APPLICATION NO. APPLICATION NO. APPLICATION NO. Certification (ZC) (Check one box for each proposed action) Authorization (ZA) Action(s) requested pursuant to ZR Special Permit (ZS) (If more than five actions are being requested, enter "see attached" below, and list ALL PROPOSED ACTIONS in the same format as below on a separate sheet titled "Proposed Zoning Special Permits/ Authorization/ Certifications.") TO MODIFY: SECTION NO. PURSUANT TO: ZONING RESOLUTION SECTION NUMBER ZONING RESOLUTION SECTION TITLE (If applicable) HAS A DRAFT RESTRICTIVE DECLARATION BEEN INCLUDED WITH THIS APPLICATION? NO WILL ALL PARTIES IN INTEREST TO THE PROPERTY AGREE TO A RESTRICTIVE DECLARATION IF REQUIRED? Property ownership/ interest YES YES NO CHECK APPLICABLE BOX(ES) (If more than one box is checked in the left column, please explain below). APPLICANT: APPLICANT: IS OWNER OF SUBJECT PROPERTY IS A CITY AGENCY IS LESSEE OF SUBJECT PROPERTY IS A STATE OR FEDERAL AGENCY HAS CONTRACT TO LEASE/BUY SUBJECT PROPERTY IS OTHER (explain real property interest below) Discussion of findings STATEMENT IN SUPPORT OF REQUIRED ZONING RESOLUTION FINDINGS/DECLARATION OF COMPLIANCE (This is the same discussion/statement as in Attachment #11. If it fits below, it may be put here instead of in a separate attachment. If Attachment #11 has been completed, you may leave this area blank). sac 0505 pdf American LegalNet, Inc. www.FormsWorkflow.com