Form HPD4 "CONH Pilot Program Building Anti-harassment Checklist" - New York City

What Is Form HPD4?

This is a legal form that was released by the New York City Department of Buildings - a government authority operating within New York City. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2021;
  • The latest edition provided by the New York City Department of Buildings;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HPD4 by clicking the link below or browse more documents and templates provided by the New York City Department of Buildings.

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Download Form HPD4 "CONH Pilot Program Building Anti-harassment Checklist" - New York City

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HPD4: CONH Pilot Program
Building Anti-Harassment Checklist
Job No.
______________________________
FORM MUST BE TYPEWRITTEN
1
LOCATION INFORMATION (Required for all applications)
House No(s)
Street Name
Work Proposed on Floor No(s)
Borough
Block
Lot
BIN
CB No.
2
APPLICANT OF RECORD (Required for all applications)
Last Name
First Name
MI
Bus. Name
Bus. Phone
Bus. Address
Bus. Fax
City
State
Zip
Mobile Phone
Email Address
License No.
PE
RA
3
COVERED CATEGORIES OF WORK (per NYC Administrative Code § 28-505.3. ‒ Required for all applications)
Identify the work type of the Job Number entered above by answering YES or NO to every item.
YES
NO Demolition of all or part of the building
Change of use or occupancy of all or part of a dwelling unit, any residential portion of the building, or any part of the building
YES
NO
serving such dwelling units
An alteration resulting in the addition or removal of kitchens or bathrooms, an increase or decrease in the number of dwelling
YES
NO
units, or any change to the layout, configuration, or location of any portion of any dwelling unit
YES
NO An application for a new or amended Certificate of Occupancy
YES
NO Removal of a central heating system and replacement with an individually metered heating system ‒ on or after Sept. 1, 2019
4
EXEMPTIONS
If any box in Section 3 is checked YES, select all of the listed exemptions that apply. The supporting documentation or additional information
indicated for each option selected must be provided.
The work is solely tor the purpose of either (1) making the public areas of the building accessible to persons with disabilities without altering
the configuration of any dwelling unit or rooming unit, or (2) making the interior or the entrance to a dwelling unit or rooming unit accessible to
persons with disabilities.
The work will be performed by a City agency or a contractor pursuant to a City agency contract. Agency name: ________________________
The building has an administrator currently appointed pursuant to Article 7-A of the Real Property Actions and Proceedings Law (RPAPL). A
copy of the court order appointing the RPAPL Article 7-A Administrator is attached.
The building is being demolished pursuant to a declaration of an immediate emergency or emergency demolition order issued by the
Department of Buildings (DOB). A copy of the DOB Emergency Declaration is attached.
The building has been transferred to a third party transferee or subsequent transferee under the Housing Preservation and Development
(HPD) Third Party Transfer Program. A copy of the Third Party Transfer letter on HPD letterhead is attached.
The building owner has entered into a regulatory agreement with HPD. A copy of the Restrictive Declaration is attached.
5
CERTIFICATION DECLARATION
If any box in Section 3 is checked YES and Section 4 has no checked boxes, one of the options provided in this section must be checked and
the supporting document indicated must be submitted with this form.
An HPD Certification of No Harassment (CONH) and a copy of the affidavit submitted to HPD is attached.
An HPD Exemption from the Requirement to Obtain a CONH and a copy of the affidavit submitted to HPD is attached.
6
APPLICANT STATEMENT & SIGNATURES (Required for all applications)
Falsification of any statement is a misdemeanor and is punishable by a
Name (please print)
fine or imprisonment, or both. It is unlawful to give to a City employee, or
for a City employee to accept, any benefit, monetary or otherwise, either
as a gratuity for properly performing the job or in exchange for special
consideration. Violation is punishable by imprisonment or fine or both.
I
Signature
Date
understand that if I am found after hearing to have knowingly or
negligently made a false statement or to have knowingly or negligently
falsified or allowed to be falsified any certificate, form, signed statement,
application, report or certification of the correction of a violation required
PE/RA Seal ‒ apply seal, then sign and date over seal
under the provisions of this Code or of a rule of any agency, I may be
nyc.gov/buildings
Rev. 05/21
HPD4: CONH Pilot Program
Building Anti-Harassment Checklist
Job No.
______________________________
FORM MUST BE TYPEWRITTEN
1
LOCATION INFORMATION (Required for all applications)
House No(s)
Street Name
Work Proposed on Floor No(s)
Borough
Block
Lot
BIN
CB No.
2
APPLICANT OF RECORD (Required for all applications)
Last Name
First Name
MI
Bus. Name
Bus. Phone
Bus. Address
Bus. Fax
City
State
Zip
Mobile Phone
Email Address
License No.
PE
RA
3
COVERED CATEGORIES OF WORK (per NYC Administrative Code § 28-505.3. ‒ Required for all applications)
Identify the work type of the Job Number entered above by answering YES or NO to every item.
YES
NO Demolition of all or part of the building
Change of use or occupancy of all or part of a dwelling unit, any residential portion of the building, or any part of the building
YES
NO
serving such dwelling units
An alteration resulting in the addition or removal of kitchens or bathrooms, an increase or decrease in the number of dwelling
YES
NO
units, or any change to the layout, configuration, or location of any portion of any dwelling unit
YES
NO An application for a new or amended Certificate of Occupancy
YES
NO Removal of a central heating system and replacement with an individually metered heating system ‒ on or after Sept. 1, 2019
4
EXEMPTIONS
If any box in Section 3 is checked YES, select all of the listed exemptions that apply. The supporting documentation or additional information
indicated for each option selected must be provided.
The work is solely tor the purpose of either (1) making the public areas of the building accessible to persons with disabilities without altering
the configuration of any dwelling unit or rooming unit, or (2) making the interior or the entrance to a dwelling unit or rooming unit accessible to
persons with disabilities.
The work will be performed by a City agency or a contractor pursuant to a City agency contract. Agency name: ________________________
The building has an administrator currently appointed pursuant to Article 7-A of the Real Property Actions and Proceedings Law (RPAPL). A
copy of the court order appointing the RPAPL Article 7-A Administrator is attached.
The building is being demolished pursuant to a declaration of an immediate emergency or emergency demolition order issued by the
Department of Buildings (DOB). A copy of the DOB Emergency Declaration is attached.
The building has been transferred to a third party transferee or subsequent transferee under the Housing Preservation and Development
(HPD) Third Party Transfer Program. A copy of the Third Party Transfer letter on HPD letterhead is attached.
The building owner has entered into a regulatory agreement with HPD. A copy of the Restrictive Declaration is attached.
5
CERTIFICATION DECLARATION
If any box in Section 3 is checked YES and Section 4 has no checked boxes, one of the options provided in this section must be checked and
the supporting document indicated must be submitted with this form.
An HPD Certification of No Harassment (CONH) and a copy of the affidavit submitted to HPD is attached.
An HPD Exemption from the Requirement to Obtain a CONH and a copy of the affidavit submitted to HPD is attached.
6
APPLICANT STATEMENT & SIGNATURES (Required for all applications)
Falsification of any statement is a misdemeanor and is punishable by a
Name (please print)
fine or imprisonment, or both. It is unlawful to give to a City employee, or
for a City employee to accept, any benefit, monetary or otherwise, either
as a gratuity for properly performing the job or in exchange for special
consideration. Violation is punishable by imprisonment or fine or both.
I
Signature
Date
understand that if I am found after hearing to have knowingly or
negligently made a false statement or to have knowingly or negligently
falsified or allowed to be falsified any certificate, form, signed statement,
application, report or certification of the correction of a violation required
PE/RA Seal ‒ apply seal, then sign and date over seal
under the provisions of this Code or of a rule of any agency, I may be
nyc.gov/buildings
Rev. 05/21