FDNY Bureau of Fire Prevention Violation Order form, date unknown

NYC 9/11 Public Portal Document

1 '

■A sr£U050i ■■ /" AFFIDAVIT (CERTIFICATE*) OF SERVICE jJ

STATE OF NEW YORK ) COUNTY OF 'P _________

theiundersigned being duly sworn*, deposes and says, that s/lie is not a party to th^tion and is over eighteen (18) years of age, that on 19 , at O—' p.m./a.m. at [address:] ' _____________ ________ ._____ ______________________ ___________________________ > served the attached Notice of Violation and Hearing on the Respondent named herein, as follows:

1. Individual Respondent

□ by delivering a true copy to [insert name:] respondent. \ '

2. Partnership Respondent

□ by delivering a true copy to [insert name:] who is the [insert position;] of said respondent.

3. Corporate Respondent

□ by delivering a true copy to [insert name:] who is the [insert position:] of said respondent.

4. Affixing of Notice of Violation and Hearing

A. .1 attempted to personally serve the attached Notice of Violation and Hearing on the respondent named herein but was unable to do so because, having entered the premises and having identified myself, I was:

1. □advised by [insert name;] that the respondent was not present;

2. □advised by [insert name:]______________________________ that an appropriate representative of the partnership respondent or corporate respondent was not present;

3. □unable to secure identification of the person(s) present;

4. □advised by [insert name;] that no officer, director, managing agent, agent, or partner of respondent partnership/corporatiOn was present. \

B’. ' □Thereupon, I affixed the Notice of Violation and Hearing at the foregoing location in the following place; ______ _______________________________________________________

[The following is. to be completed if a person was served with the Notice of Violation and Hearing.] ■■

gf Deponent deScribes the individual served as follows: .

Lr---

□ Male □ White Skin □Black Hair □ 14-20 yrs □Under 5’ □Under 100 lbs □ Female.- • oBlack Skin □Brown Hair □21-35 yrs o5’0”-5’3” □ 100-130 lbs ■ □Yellow Skin □Blond Hair □36-50 yrs □5’4”-5’8” □13M60 lbs □Brown Skin □Gray Hair □51-65 yrs □5’9”-6’0” □ 161-200 lbs □Red Skin □Whife Hair □Over 65 yrs' □Over 6’ □Over 200 lbs □Balding , Other identifying characteristics:

Signature:

Printed Name;

Tax Registry Number:

Sworn to before nie on

- Signature of CertifyingpfficeC^ A *lf not sworn, this si'atem^n Pkhali cohali^m^cenificate of service.

NYC-WTC_000165992