BSA Cal. No.: _____________________________________ City of New York Board of Standards and Appeals Street Address: ___________________________________ 40 Rector Street, 9th Floor New York, NY 10006-1705 ____________________________________________________ Block: _________________ Lot(s): ____________________ Borough :__________________________________________ CERTIFICATION OF INSPECTION & COMPLIANCE ________________________________________________hereby states that I personally inspected the (Applicant, Agent, Registered Architect or Registered Engineer) premises and surrounding area on ______________________________________. In addition, I have (Date of most recent inspection) researched all relevant BSA records related to the premises, including BSA-approved plans and resolutions. Each non-compliance with the terms, conditions and/or plans of the effective prior BSA grant is explained in detail below. The specific date or time frame on which compliance will be restored, where possible to ascertain, is listed. [Note: A request to eliminate any prior condition must be part of the relief sought in the application; such request should not be made on this form] I confirm that the premises is developed and operates in accordance with the currently effective BSA-approved plans and resolution, submitted with this application. The following deviation(s) from the currently effective BSA-approved plans and/or resolution exist on the site: Area(s) of non-compliance Date(s) to achieve compliance. ______________________________________ Applicant/Agent Signature (Registered Architect/Engineer Seal as Appropriate) American LegalNet, Inc. www.FormsWorkflow.com