TOWN OF BLOOMING GROVE

COUNTY OF ORANGE

OFFICE OF BUIDING INSPECTOR

AFFIDAVIT OF APPLICANT

SECTION BLOCK LOT

Premises

State of New York:

                             SS:

    County of Orange:

                                                                                      , being duly sworn deposes and

(Name of individual signing application)

says that he/she is the applicant named above.

He/She is the and is duly authorized to perform or

                        (owner, contractor, agent, etc.)

have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his/her knowledge and belief, and that the work will be performed in the manner set forth in the application and in the plans and specifications filed therewith.

That the deponent will comply with Section 125 of the General Municipal Law that requires any individual applying for a Building Permit prove to the building department that he/she is in compliance with mandatory coverage provision of the Workmen’s Compensation Law.

Signature

Sworn to me before this  day of , 20

NOTARY PUBLIC