NYC 9/11 Public Portal Document
--
INDICATE CHANGES BELOW
PLEASE PRINT ALL INFORMATION
PREMISE ADDRESS
ADDITIONAL
PREMISE INFO
STREET NUMBER PREFIX
srREETNAME I I I I I I I I I I I I I I I I I I I I I
TYPE SUFFIX ZIP BORO Q
m
AKA ADDRESS
STREETNUMBERI I I I I I I I PREFIX I I I :
STREET NAME
TYPE 1 1 1 1 1 SUFFIX I I I
OWNER NAME
I I 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 OF OWNER F"v
s. r
DATE OF OWNER CHANGE
BILLING ADDRESS
ADDITIONAL - - -
MAILING INFO
1 1 1 1 1 1 1 1 1 1 1 1 [ 1 1 1 1 1 1
STREET NUMBER
PREFIX
STREET NAME
TYPE I I I SUFFIX I ZIP BORO
ENTER HERE FOR OUT OF TOWN ADDRESS
CITY STATE II ZIP .
REMARKS
INSPECTOR I:D
INSPECTOR L./ _- DATE ,Z 1-
EXAMINER
ENTRY CLERK '7zi ( • rA■ SWAa iii
AUDITOR ■■ ■■ ~~
NYC-WTC 000166219
OCR can misread numbers and units. Confirm readings against the page image before using them.