City of Passaic Division of Housing

CITY OF PASSAIC DIVISION OF HOUSING

APPLICATION FOR OCCUPANCY CERTIFICATE

DATE: ______

PROPERTY ADDRESS: ______

BLOCK: ______LOT: ______BLDG: ______UNIT: ______

NAME OF CURRENT OWNER: ______

MAILING ADDRESS: ______

PHONE NUMBER: ______EMERGENCY PHONE NUMBER: ______

ALL USES:

5 RESIDENTIAL 5 COMMERCIAL 5 OTHER

PREVIOUS USE OF PREMISE: ______PREMISE WILL BE USED FOR: ______

NUMBER OF ROOMS:

LIVING ROOM: ______DINING ROOM: ______KITCHEN: ______BEDROOM: ______BATHROOM: ______

ATTIC (Y/N): ____ PART OF 2ND FLOOR? (Y/N): ____ FULL BATH (Y/N): ____ KITCHEN (Y/N): ____ BASEMENT FIN (Y/N): ____

NAME TO BE PRINTED ON OCCUPANCY CERTIFICATE:

5 OWNER 5 BUYER 5 OTHER

NAME(S): ______

IF CORPORATION, YOU MUST SUPPLY REGISTERED AGENT’S NAME ABOVE

BUSINESS NAME (IF APPLICABLE): ______

IF CORPORATION, YOU MUST SUPPLY A COPY OF YOUR REGISTRATION

MAILING ADDRESS: ______

PHONE NUMBER: ______EMERGENCY PHONE NUMBER: ______

REPORT TO BE MAILED TO:

5 OWNER 5 BUYER 5 OTHER

NAME: ______

MAILING ADDRESS: ______

AFFIDAVIT TO BE SIGNED BY APPLICANT

______OF FULL AGE, BEING DULY SWORN ON HIS OATH SAYS THAT HE/SHE IS THE OWNER (OR DULY AUTHORIZED AGENT OF THE OWNER FOR THE PURPOSE HEREIN), AGREES TO USE OR OCCUPY SAID PREMISE, OR OBTAIN PERMISSION TO PROCEED IN CONFORMITY WITH THE ACCOMPANYING STATEMENT FILED WITH THE DEPARMTENT OF COMMUNITY DEVELOPMENT-DIVISION OF HOUSING, TO COMPLY WITH THE ZONING AND PROPERTY MAINTENANCE CODE AND ALL AMENDMENTS AND SUPPLEMENTS THERETO. NOTE: THIS OCCUPANCY CERTIFICATE CERTIFIES THAT THE ABOVE REFERENCED PROPERTY IS IN COMPLIANCE WITH PASSAIC’S PROPERTY MAINTENANCE AND ZONING LAWS. IT IS NOT APPROVING, NOR DOES IS RELIEVE YOU FROM THE NEED TO OBTAIN ANY OTHER NECESSARY PERMITS OR APPROVALS, INLCUDING BUT NOT LIMITED TO CONSTRUCTION PERMITS, FIRE SAFETY ACT REQUIREMENTS AND HEALTH APPROVAL.

SWORN TO AND SUBSCRIBED BEFORE ME THIS

______DAY OF ______, ______

______

NOTARY PUBLIC SIGNATURE OF OWNER OR AGENT

MY COMMISSION EXPIRES______

======DO NOT WRITE BELOW THIS LINE======

ZONE: ______5 APPROVED 5 DENIED

CONDITION(S): ______

______

ZONING OFFICER DATE

FEES:

ESCROW $______CK# ______5 CASH RECEIPT# ______DATE ______

FIRE $______CK# ______5 CASH RECEIPT# ______DATE ______

OC $______CK# ______5 CASH RECEIPT# ______DATE ______