NYC 9/11 Public Portal Document
INDICATE CHANGES BELOW
PLEASE PRINT ALL INFORMATION
PREMISES ADDRESS E
prS*info I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
STREET NUMBER PREFIX I I I
STREET NAME | | I I I III I I I I I I I I I I I I I
TYPE SUFFIX
m 2'p I I I I I I I r I I BORO
AKA ADDRESS
. STREET NUMBER | | | | | | | | PREFIX [ I I
STREET NAME | | | | | | | | | | | | | | | | | | | | |
I
TYPE I I I I I SUFFIX I I I
i
ACCOUNT NAME (CIN) - OWNER NAME (CIO)
X - IF CHANGE IN NAME ONLY
I
I I I I I I I' I I I I I I I I I I I I I I X - IF CHANGE IN OWNER
I
DATE OF OWNER CHANGE | | ] [x^| | |
MAILING ADDRESS (CIMA)
I
ADDITIONAL
MAILING INFO I I I I I I I . I I I I I I I I I I T I T I T I I IT I I I I I I
STREET NUMBER j | | | | | | | r—r—»
lZEZJ '
STREET NAME | | J j ) j | | | j | | | | [ 1 1 1
TYPE I I I I I SUFFIX nn ZIP I I I I I I I I I I BORO
ENTER HERE FOR OUT OF TOWN ADDRESS (CIMA)
I I I I I I I I I I I I I I I I I I I I
I I I I I I I I I I I I I I I I rm
CITY I I I I I I I I I I I I I I I I STATE I I I ZIP
REMARKS
COMMENTS
INSPECTOR DATE
si^Kl^
EXAMINER DATE
ENTRY CLERK DATE
AUDITOR DATE, ’' OZZl/TZDxTZZZl
COMMENTS
INSPECTOR DATE n~txT7nxd~T~l inspector I.D.
EXAMINER DATE
rrix'^rruTTi L-J-LJ
ENTRY CLERK DATE mxTTmm
AUDITOR DATE nrT<T~ixrr~i
NYC-WTC_000166069
OCR can misread numbers and units. Confirm readings against the page image before using them.