NYC-WTC_000166105

NYC 9/11 Public Portal Document

AFFIDAVIT (CERTIFIGTE-) OFSENIfICE - — 1 - Xi 311 State o1 New YaksCountY of :` • )as: ;_.._

The undersigned being duly sworn' deposes and says: That deponent is not a party to the action and is over 18 years of age; That an 19_ at AM/PM at deponent served the within Notice of Volation and Hearing on the respondent named herein. . , .

I. Individual: ParsotW SwWee r 15 '+_., a O-a-c, x3 E i 1 _ . .. -. - ❑ M.deMering:~rttte oopy - sad resport~snt peraonelry.~ t ;_ } 1 tt . i .

II. Individual: Substituted Service - .. ❑ by delivering a true' oo0y'tti _.... - ` f i : d:aiwk * ~' -""'`.`..~"'_ —'~ "a -person of suitable age -Said premises is respondents : r t ' acttiar-pae-a eris"iries4 da'~ageig naae oruwel'plece of geode L_..,~__' .' e

_—, - -j ,_- - - --.( Ill. Corporation •R Qtry delivering..a true'copy to 3'n~ Ar ~• - 47.. - - - at saW eorporetion. ._ ;.~•.. .. -Y' ~- -rte=--

IV. Deliveryto Employee at Premises: _ . • "c .- rr_ . .. — . . _ _ - ,. _ ; : . t= ❑ by delivering a true copy to respondent's employee at the above location: (answer A and B) •~ ~ - A. 1 attempted to personally serve the herein Notice of Violation on the respondent named herein but was unable to do so because, havjng entered the premises and having identified -. .. myself, I was: -. ._ .. . _ - : - U . 1. ❑ advised by that the reepOrrdeiil moresriot dten present and p`rensses is neither respondent'sactual place of busirtess roc J ngiousa 2. ❑ unable to secure identification of the person(s) present; . - '1 :.: . - - - -,

a ❑ advised by that noofficer, director managing agent or agent of resporMenl oorporatwn"was present B. Thereupon, I delivered a copy of the herein Notice of Violation to - _ - ~ ~ ..4• whom I believe to be an employee of respondent at the premises because: (check 1, 2or 3)• - --' .a ` - --- -- - - _ 1. E] Employee so identified him/herself; --- -

2. ❑ Employee was performing work consistent with being employed by the respondent; or , _ n - - ._ ._ _ - -- - 3. Q Olhec

Description of Individual. (This must be completed for all types of service except corporate, Number Ill, above.) - - - - - - - Deponent describes the individual served as follows: - - - - -- •--

❑ Male ❑ White Skin O Black Hair -. O 14-20 - - —• -.11 Under 5' i ' -i ti Under 100 lbs El Female O Black Skin ❑ Brown Hair ❑ 21.35 -- - O 5'0.5'3' - - - "--'- U 100-130 .O Yellow Skin [1 Blond Hair O36-50 O 5'4'558 _ :. O -131-1W G Brown Skin ' O Gray Hair __ O51-65 - --- ' '' ' ❑ 59.8'0• . - O1 181-200' • Red Skin O Red-Hair, ; p = -, -❑-Over 65 - - - - - .O Over 5' O,bver 200 n1: •. . . ... O White Hair - _. . .. -!uN — . -- — --- - 'O Battling - -

Other identifying characteristics: r - - _. . . ._ _. - - _ - - --' ----- - - - --- - — '- r - — - - ---

Sworn to before me on - 19_. - - ', ' -

a nauaf rf crmavuc nrrEn .. .. `•1- ~.. s ...

• If not sworn, this statement shall constitute a certificate of service. _ _. _., .

3: .~T _ '_ ~ - .tar ,-~•. 6T: - -- - -- --- - -----

NYC-WTC 000166200