City of New York Board of Standards and Appeals 40 Rector Street, 9th Floor New York, NY 10006-1705 Phone: (212) 788-8500 Fax: (212) 788-8769 www.nyc.gov/bsa ZONING (BZ) CALENDAR Application Form BSA APPLICATION NO. _____________________ CEQR NO. ___________________________________ _______________________________________________ NAME OF APPLICANT OWNER OF RECORD _______________________________________________ ADDRESS _______________________________________________ ADDRESS _______________________________________________ CITY STATE ZIP _______________________________________________ AREA CODE TELEPHONE _______________________________________________ LESSEE / CONTRACT VENDEE _______________________________________________ AREA CODE FAX _______________________________________________ ADDRESS _______________________________________________ EMAIL Applicant/ Owner _______________________________________________ _______________________________________________ CITY STATE ZIP Section A _______________________________________________ CITY STATE ZIP Site Data ____________________________________________________________ ______________ STREET ADDRESS (INCLUDE ANY A/K/A) Section B ZIP CODE _________________________________________________________________________________________________________ DESCRIPTION OF PROPERTY BY BOUNDING OR CROSS STREETS _______ BLOCK __________ LOT(S) _______________________ CITY COUNCIL MEMBER Section C Dept of Building Decision Section D _______________ BOROUGH ____________________ COMMUNITY DISTRICT . ________________________________________ ZONING DISTRICT (include special district, if any) BSA AUTHORIZING SECTION(S) ________________ for VARIANCE _______________________________ LANDMARK/HISTORIC DISTRICT _________________________ ZONINNG MAP NUMBER SPECIAL PERMIT (Including 11-41) Section(s) of the Zoning Resolution to be varied ______________________________________________________ DOB Decision (Objection/ Denial) date: __________________ Acting on Application No: __________________ (LEGALIZATION YES NO IN PART ) Description Section E BSA History and Related Actions If “YES” to any of the below questions, please explain in the STATEMENT OF FACTS YES NO 1. Has the premises been the subject of any previous BSA application(s)? ………………………………… PRIOR BSA APPLICATION NO(S): ____________________________________ 2. Are there any applications concerning the premises pending before any other government agency?.... 3. Is the property the subject of any court action?....................................................................................... 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