Form Zrd1 - Zoning Resolution Determination Form Page 3

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ZRD1: Zoning Resolution Determination Form
PAGE 3
7 Description of Request
(use this section if additional space is required for description)
NOTE: Department of Buildings Determination will be issued on the ZRD1 Response Form
8 Statements and Signature
Required for all requests
(If Attorney, include ‘Esquire’ or ‘Esq.’ in signature)
Name (please print)
I hereby state that all of the above information is correct and complete to the best of
my knowledge. 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
Signature
Date
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.
P.E. / R.A. Seal (apply seal, then sign and date over seal –
not required for Attorneys on unfiled applications)
ADMINISTRATIVE USE ONLY
Control #:
Reviewed By:
Date
01/18

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