Form L2 - Requests For Overrides, Reductions, Or Waivers Of Civil Penalties For Work Without A Permit And Stop Work Order Violations Page 2
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Affidavit of Reduction (Only required if reduction is requested. Affidavit needs to be provided by PE or RA. If the reduction
4
request relates to a Limited Alteration Application—LAA—then the affidavit may be provided by another licensee type, such as a
licensed plumber.)
___________________________________________________________, being duly sworn, deposes and says:
1.
This affidavit is submitted in support of the request indicated in Section 1 of this form (Job and Request Information).
2.
On __________________________ (date) at _____________ (
am
pm) I inspected the above-captioned premises to determine whether
the work covered by the application was commenced without benefit of a New York City Department of Buildings Permit.
3.
This affidavit is being submitted to the New York City Department of Buildings within two business days of my inspection.
My inspection revealed that the following work, (written description must be provided below with at least four (4) supporting photographs in
4.
order to be accepted for consideration), filed for in the application, was completed without benefit of a permit. (Photographs need to have
been taken within two business days of inspection.)
5.
Job #
Violation #
Internal Use Only — Preliminary Borough Review
Building Classification ___________________ Reduction Amt $_________
Name (please print)
Signature
Date
5 PE/RA/Other Licensee Applicant Data (Only required if reduction is requested)
Name (please print)
Last Name
First Name
M.I.
Business Name
Phone
Address
Signature
Date
City
State
Zip Code
PE
RA
Other_______________ License No. ________________
Falsification of any statement is a misdemeanor and is punishable by a fine or imprisonment, or
both. It is unlawful to give to a city employee, or for a city employee to accept, any benefit,
monetary or otherwise, either as a gratuity for properly performing the job or in exchange for
special consideration. Violation is punishable by imprisonment or fine or both.
PE / RA / Other Seal (apply seal, then sign and date over seal)
6 Notarization
Internal Use Only
Borough Commissioner Review
State of New York, County of
___________________________
Approved
Denied
Reduction Amt $_______
Sworn to before me this
day of
20
Approval/Denial Reason:
Name (please print)
Notary Seal
1st Level Signature
Date
2nd Level Review—Fiscal
Notary Signature
Approved
Denied
Reduction Amt $_______
Approval/Denial Reason:
Tracking #: ____________
Name (please print)
Owner or Authorized Designee Signature
Date
2nd Level Signature
Date
Rev. 08/17
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