City of New York Board of Standards and Appeals 250 Broadway, 29th Floor New York, NY 10007 Phone: (212) 386-0009 www.nyc.gov/bsa Section A Applicant/ Owner _______________________________________________ NAME OF APPLICANT _______________________________________________ ADDRESS _______________________________________________ CITY STATE ZIP _______________________________________________ AREA CODE TELEPHONE _______________________________________________ AREA CODE FAX _______________________________________________ EMAIL Letter of Substantial Compliance (LSC) Application Form BSA APPLICATION NO. _____________________ _______________________________________________ OWNER OF RECORD _______________________________________________ ADDRESS _______________________________________________ CITY STATE ZIP _______________________________________________ LESSEE / CONTRACT VENDEE _______________________________________________ ADDRESS _______________________________________________ STATE ZIP CITY Section B Site Data _____________________________________________________ STREET ADDRESS (INCLUDE ANY A/K/A) ___________ ZIP CODE _________________________________________________________________________________________________________ DESCRIPTION OF PROPERTY BY BOUNDING OR CROSS STREETS _______ BLOCK __________ LOT(S) ____________________ COMMUNITY DISTRICT . ________________________________________ ZONING DISTRICT (include special district, if any) _______________ BOROUGH _______________________________ LANDMARK/HISTORIC DISTRICT _________________________ ZONING MAP NUMBER _______________________ CITY COUNCIL MEMBER Section D Description (LEGALIZATION YES NO IN PART) Section E Related Actions If "YES" to any of the below questions, please explain in the STATEMENT OF FACTS YES NO 1. Are there any applications concerning the premises pending before any other government agency?.... 2. Is the property the subject of any court action?....................................................................................... 3. Has a zoning changed since the last approval?...................................................................................... Section F Signature I HEREBY AFFIRM THAT BASED ON INFORMATION AND BELIEF, THE ABOVE STATEMENTS AND THE STATEMENTS CONTAINED IN THE PAPERS ARE TRUE. _______________________________________________________ SWORN TO ME THIS _____ DAY OF_______20___ Signature of Applicant, Corporate Officer or Other Authorized Representative __________________________ Print Name __________________________ __________________________________________ Title NOTARY PUBLIC American LegalNet, Inc. www.FormsWorkFlow.com