NYC 9/11 Public Portal Document
INDICATE CHANGES BELOW
_EASE PRINT ALL INFORMATI
PREMISES ADDRESS
ADDITIONAL
PREMISES INFO
STREET NUMBER I PREFIX
m
STREET NAME
TYPE
1 1 1 1 1 SUFFIX I I I zir I I I I l l I I I I BORO ❑
AKA ADDRESS
STREET NUMBER
I PREFIX
m
STREET NAME
TYPE SUFFIX
m
ACCOUNT NAME (CIN) - OWNER NAME (CIO)
X- IF CHANGE IN NAME ONLY
X - IF CHANGE IN OWNER
DATE OF OWNER CHANGE
MAILING ADDRESS (CIMA)
ADDITIONAL 1 1 1 1 1 1 1 1
MAILING INFO
STREET NUMBER PREFIX II
STREET NAME
TYPE
I SUFFIX
m ZIP
BOROLJ
ENTER HERE FOR OUT OF TOWN ADDRESS (CIMA)
CITY I l l I l l I l l I l l I l l I STATE m ZIP
I J I I J I I I J
REMARKS
INSPECTOR
EXAMINER
0c 17111 ATE
DATE
INSPECTOR I.D. COMMENTS
ENTRY CLERK DATE 7
AUDITOR DATE
SECOND INSPECTION
INSPECTOR I.D.
COMMENTS
INSPECTOR DATE I I
EXAMINER DATE
ENTRY CLERK DATE
AUDITOR DATE
NYC-WTC 000166170
OCR can misread numbers and units. Confirm readings against the page image before using them.