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State of New York
County of ________________
___________________________________________, being duly
sworn, deposes and says;
that he (she) is the applicant (or agent of the
applicant) named in the Application for Building Permit
dated __________________________________ relating to
construction or other work to be performed on,
or in connection with, the premises located as
indicated above; that the estimated cost stated in said
application
of the construction or other work described therein
was_______________Dollars ($_____________);
that the actual final cost of such construction or
other work was________________Dollars ($________________).
Application is hereby made for issuance of a
Certificate of Occupancy for the structure on these
premises.
Applicant states that he has examined the approved plans
and that to the best of his knowledge and belief the
structure has been erected in accordance therewith and in
accordance with applicable provisions of law.
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