Appeals (A) Calendar Application Form

250 Broadway, 29th Floor New York, NY 10007 212-386-0009 - Phone 646-500-6271 - Fax www.nyc.gov/bsa APPEALS (A) CALENDAR Application Form BSA APPLICATION NO.__________________________ Section A Applicant/ Owner _______________________________________________ NAME OF APPLICANT _______________________________________________ ADDRESS ________________________________________ _______ CITY STATE ZIP _______________________________________________ AREA CODE TELEPHONE _______________________________________________ AREA CODE FAX _______________________________________________ EMAIL _____________________________________________________ OWNER OF RECORD _____________________________________________________ ADDRESS ____________________________________________________ CITY STATE ZIP _____________________________________________________ LESSEE / CONTRACT VENDEE _____________________________________________________ ADDRESS _____________________________________________________ CITY STATE ZIP Section B Site Data _____________________________________________________________________________________ STREET ADDRESS (INCLUDE ANY A/K/A) ___________________________ ZIP CODE _________________________________________________________________________________________________________ DESCRIPTION OF PROPERTY BY BOUNDING OR CROSS STREETS _______ BLOCK _____________________________ ____________________________ COMMUNITY BOARD NO. LANDMARK/ HISTORIC DISTRICT . __________________________ _________ ______________________________ ______________________________ CITY COUNCILMEMBER EXISTING ZONING DISTRICT ZONING MAP NUMBER (include special zoning district, if any) _________ LOT (S) _______________ BOROUGH Section C Application Type Dept. of Building or other Agency Appeals Certificate of Occupancy Modification Date of Final Determination Legalization Yes No Variance to Building, MDL or Other Code Waivers to GCL 35/36 Vested Rights _______________ Acting on Application No. ____________________ Section D Description In part Section E BSA History and Related Actions If "YES" to any of the below questions, please explain in the STATEMENT OF FACTS 1. Has the premises been the subject of any previous BSA application(s)............................................... If yes, Prior BSA No __________________________________________________________________ 2. Are there any applications concerning the premises pending before any other government agency?.......... 3. Is the property the subject of any court action?............................................................................................. YES NO Section G 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