NYC Department of Transportation
Bureau of Permit Management and Construction Control
55 Water Street, New York, NY 10041
AFFIDAVIT OF OWNERSHIP
This form must be printed out. Type or print clearly. Mail to:
New York City Department of Transportation
Permit Management & Construction Control
Permit by Mail
55 Water Street, Concourse Level
New York, NY 10041
STATE OF NEW YORK
I, _________________________________________, being duly sworn, depose and say the
1. I am the owner of premises_______________________________________________
in the Borough of _______________________________________________________
2. I personally will perform the repairs to the sidewalk of the said premises.
3. I am aware that the law requires that if the said repairs are to be made by any person other
than myself, the required Workers Compensation Insurance, and Commercial General Liability
Insurance policy must be filed with the Department of Transportation.
(Signature of Owner)
State of New York, County of ____________________________On the ________________ of
________________, before me personally came ______________________________________ to
me known to be the individual described in and who executed the forgoing instrument, and
acknowledged that _________________________________________________________________
executed the same.