(To be filed when job is completed)

     PERMIT NUMBER

SECTION BLOCK LOT

TOWN OF BLOOMING GROVE

COUNTY OF ORANGE

OFFICE OF BUILDING INSPECTOR

AFFIDAVIT OF SUPERINTENDENT

State of  New York:

                     SS:

 County of Orange:

I, , the person who observed the work for

                    (name)

which a Certificate of Occupancy/Compliance is being sought, hereby certifies that the building constructed under Town of Blooming Grove Permit Number  has been constructed as per plans and specifications accepted for the building permit, and that all work and materials meet the standards and specifications for which they were designed and that the building/structure is safe for human occupancy/use.

                                                                                    Signature

Sworn to before me this

day of , 20

NOTARY PUBLIC