HomeMy WebLinkAboutBLD-26-53Town of Ithaca June 1, 2026
Record No: BLD-26-
53
TOI - General Building
Permit Application
Status: Active
Submitted On: 4/21/2026
Primary Location
103 Bundy Rd Unit Brookdale
Senior Living
Ithaca, NY 14850
Owner
AHC Purchaser/Brookdale
Senior Living
6737 W Washington St 2300
Milwaukee, WI 53214
Applicant
Randall Cerone
704-267-0005
randy@venture-gc.com
8230 Poplar Tent Rd
Suite 101
Concord, NC 28027
Applicant Information
Applicant Type
Contractor
Who will be performing the work?
Contractor
If the applicant is NOT the owner, a letter/email from owner designating the applicant as
agent or a copy of the contract with owner's signature will need to be provided
Is the primary point of contact for permit communication
different than the applicant?
No
6/1/26, 8:39 AM BLD-26-53
https://ithacany.workflow.opengov.com/#/explore/records/40448/form 1/17
Detailed Description of Work
Description*
Dining- West Side of
Cabinets (Where drain is) Cabinets are a pressed wood siding,
remaining deteriorated floor
inside the west side cabinet
and on the rotted wood debris
and exposed concrete floor
under the west side cabinet
(~30 square feet of visible
microbial growth).
Remove all cabinets in the delineated section. Remove rotted
wood remnants from under cabinet.
Dining- North Wall
Bottom two feet of the north
side wall and baseboard
molding (~18 square feet of
visible microbial growth on
bottom one foot)
Remove Bottom 2 feet of wall and molding. Exposed cavities a d concrete surfaces that
were exposed
will be dried, HEPA vacuumed, and cleaned with a broadspectrum biocide. We will check
for additional microbial growth on
backside of shared kitchen wall.
Dining- Near West Side
Cabinets
Vinyl Plank Flooring Clean approximately 20 square foot section with a broadspectrum
biocide. Dry thoroughly.
Water damaged to wall and cabinets in main ding room where plumbing drain meets
floor drain.
Project Information
Type of Work*
Alteration
Building Name
Brookdale Ithaca 103C
6/1/26, 8:39 AM BLD-26-53
https://ithacany.workflow.opengov.com/#/explore/records/40448/form 2/17
Are you applying for 1 year Permit or multi-year Permit?*
1 Year
Estimated Start Date
04/23/2026
Estimated Project Cost*
20000
Number of Dwelling Units Current
–
Water Supply*
Municipal
Sewage Disposal *
Municipal
Is there currently a sprinkler system?*
Yes
Heating type (main heating system)*
N/A
Will there be plumbing work associated with this project?*
No
Will there be electrical work associated with this project?*
No
Will there be ANY soil disturbance associated with this
project?*
No
Will there be work conducted in a Town Right of Way or
within a Town easement? *
No
Please Note that the Building Permit will not be issued until a SWPPP has been approved by
the Town of Ithaca Engineering Department or confirmed that a SWPPP approval is not
required.
Will Special Inspections be Required for this Project?*
No
6/1/26, 8:39 AM BLD-26-53
https://ithacany.workflow.opengov.com/#/explore/records/40448/form 3/17
Ithaca Energy Code Supplement
Is your project new construction (excluding additions and
renovations that are not specified in this list), an addition(s)
of 500 square feet or larger to single family dwellings or
two-family dwellings, an addition(s) of 1,000 square feet or
larger to buildings other than single family dwellings or two-
family dwellings, or a MAJOR RENOVATIONS, as defined in
Section 144-3.*
No
Engineer Info
Is there an Engineer for this project?*
No
Architect Info
Is there an Architect for this project?*
No
Building Specs
Current Building Height Existing Basement Square Footage
Existing First Floor Square Footage Existing Second floor Square Footage
Existing Over Second floor Square Footage Existing Number of Rooms
–
Check each item that will be changing due to this project.
6/1/26, 8:39 AM BLD-26-53
https://ithacany.workflow.opengov.com/#/explore/records/40448/form 4/17
Building Height Basement Square Footage
First Fl Square Footage Second Fl Square Footaage
Over 2nd Fl Square Footage Number of Rooms
Number of Bedrooms Number of Dwelling Units
Water Supply Sewage Disposal
Proposed Set-backs (if applicable)
Front Yard
–
Rear Yard
–
Side yard
–
Side yard
–
Lot Coverage %
Contractor's Insurance Details or Homeowner Exemption
Current Insurance Certificate for both Workers' Comp and Workers' Disability must be
provided for a permit to be issued. If you have not done so, complete the
Contractor/Business Registration and upload the certificates. If the Contractor/Business is
EXEMPT from carrying insurance, the CE-200 form needs to be completed and uploaded
with the permit.
6/1/26, 8:39 AM BLD-26-53
https://ithacany.workflow.opengov.com/#/explore/records/40448/form 5/17
Work is being done by:*
Contractor/Business with employees/paid help
Current Workers' Comp and Workers' Disability need to be on file in the
"Contractor/Business" Permit. If you have not filed a "Contractor/Business Registration"
prior, it can be done HERE .
AFFIDAVIT
6/1/26, 8:39 AM BLD-26-53
https://ithacany.workflow.opengov.com/#/explore/records/40448/form 6/17
I understand that if a building permit CANNOT be issued within 90 days of my initial application
because I failed to provide information requested or because I failed to comply with any Legislative
Board Conditions, my building permit application will be withdrawn without further action and I will
need to reapply and pay a new permit application fee.
I am applying for permission to do the above in accordance with provisions of the Zoning
Ordinance and other Laws and Regulations of the Town of Ithaca, or others having jurisdiction. I
affirm that the structure for which this permit will be issued, or has been issued, will be built, or has
been built, according to the latest standards of the New York State Uniform Fire Prevention and
Building Code, and all other applicable state and local laws, ordinances and regulations
I affirm that the approved design plans will not be deviated from without prior approval from the
Architect/Engineer of record, if applicable, and the Town of Ithaca Code Enforcement Department.
I understand that I am responsible to ensure that all inspections will be completed as required by
the Town, and no structure will be used in violation of Federal, State and Local laws, codes and
ordinances.
I affirm that the statements and information contained in this application and submitted in
conjunction with this application are true and accurate to the best of my knowledge.
I agree that my electronic signature is equivalent to a
handwritten signature and is binding for all purposes
related to this transaction
Randall Cerone
Apr 21, 2026
PAYMENT INFORMATION
6/1/26, 8:39 AM BLD-26-53
https://ithacany.workflow.opengov.com/#/explore/records/40448/form 7/17
After submission, Code Department Administration will review the application and materials
provided. After review, and email with instructions for paying the fee online with credit card
or E-check will be sent to the applicant.
If it is preferred to pay by check, cash or money order:
*Mail to Code Enforcement, Town Hall 215 N. Tioga St, Ithaca, NY 14850
*Drop off during business hours to Town Hall M-F 8-4
*Place in locked box next to the door on the Buffalo St side of Town Hall
Code Officer/Internal Only-Review
Inspector Assigned:
Jessica Hull
Permit Type
Institutional Renovation/Alteration
Tax Parcel Number (Permit & CO)
27.-1-11.3
Permit Extension Requested
No
Is Planning Dept approval required?
No
Is Engineering Dept approval required?
No
How many years is the permit?
1 year
Complete this section before issuing Permit and Certificate
Scope of Work (P)/Description (CO)
Building 103C – Repair water-damaged wall, flooring, and cabinetry in the main dining
room at area where plumbing drain connects to floor drain. Scope includes removal and
replacement of damaged cabinets, lower portion of affected wall finishes, flooring, and
associated finish materials, with cleaning/remediation of exposed surfaces as needed.
6/1/26, 8:39 AM BLD-26-53
https://ithacany.workflow.opengov.com/#/explore/records/40448/form 8/17
Is there more than one NYS Use Occupancy class?
No
NYS Use Occupancy Classification (Permit & CO)
I2 - Institutional
Zoning Use (Permit & CO)
PDZ10
Type of Construction (Permit & CO)
V-B
Is a sprinkler present? (Permit & CO)
Yes
Is a sprinkler required by building code? (CO)
Yes
Date Permit Issued (Permit)
05/19/2026
Comments/Conditions (Permit)
Special Conditions (CO/TCO)
Code Officer Name Printed on Document
Jessica Hull
Date of Last Inspection
–
6/1/26, 8:39 AM BLD-26-53
https://ithacany.workflow.opengov.com/#/explore/records/40448/form 9/17
Types of Inspections
1. 911 ADDRESSING
2. HANDICAP ACCESSIBILITY COMPLIANCE
3. AIR BARRIER
4. HVAC: ROUGH AND/OR FINAL
5. AIR SEALING/INSULATION /ENERGYCODE
6. MECHANICAL: ROUGH AND/OR FINAL
7. ANCHORING
8. PLUMBING: ROUGH, DWV, SUPPLY, UNDER SLAB AND/OR FINAL
9. BACK-FILL/DRAINAGE
10. REBAR/REINFORCEMENT
11. DEMOLITION
12. ROOFING: ICE/ WATER AND UNDERLAYMENT
13. ELECTRICAL: ROUGH, SERVICE, BONDING, AND/OR FINAL
14. SOLAR ARRAY: GROUND OR ROOF MOUNTED
15. FIRE ALARM
16. FIRE RATED CONSTRUCTION
17. SPECIAL INSPECTIONS
18. FLASHING
19. TRENCH
20. FOOTING AND/OR FOUNDATION
21. ANY PERMITS OR APPROVALS FROM OTHER AGENCIES OR DEPARTMENTS
22. FUEL GAS ROUGH AND/OR FINAL
23. ZONING COMPLIANCE
24. SPRINKLER SYSTEM
25. FRAMING
26. SHEATHING
27. UNDER SLAB
28. ELEVATOR
29. FINAL
Number of Inspections to be Displayed on Permit (1-28)
3
1. Inspection
DEMOLITION
2. Inspection
FRAMING
3. Inspection
FINAL
6/1/26, 8:39 AM BLD-26-53
https://ithacany.workflow.opengov.com/#/explore/records/40448/form 10/17
Historical Background
Date Submitted Municity App #
Fee's - Internal Use Only
Working without a permit
–
Commercial Truss Sticker inspection
–
Before/After hours Inspection
–
Holiday Inspection Fee
–
Requesting a fee refund TCO/ TCC Fee Applied
–
Renewal Letter Information
Contact by this date for final inspection
–
Amount of Renewal
–
Expiration of Existing Permit
–
Permit Close Out Without Certificate
Reason permit was closed
–
6/1/26, 8:39 AM BLD-26-53
https://ithacany.workflow.opengov.com/#/explore/records/40448/form 11/17
Attachments
Screenshot_20260421_112408_Gmail.jpg
Uploaded by Randall Cerone on Apr 21, 2026 at 11:24 AM
Insurance.pdf
Uploaded by Code Enforcement Permit Email on Apr 23, 2026 at 1:16 PM
Administrative Review-Result Letter.pdf
Uploaded on Apr 23, 2026 at 1:17 PM
image011.png
Uploaded by Randall Cerone on Apr 27, 2026 at 6:12 PM
image012.png
Uploaded by Randall Cerone on Apr 27, 2026 at 6:13 PM
image013.jpg
Uploaded by Randall Cerone on Apr 27, 2026 at 6:13 PM
Administrative Review-1-Result Letter.pdf
Uploaded on Apr 28, 2026 at 9:39 AM
U2-5229 Brookdale Ithaca AL NY State Mold Remediat_260429_103543 (002).pdf
Uploaded by Jessica Hull on Apr 29, 2026 at 2:29 PM
Email Confirmed No Plumbing Permit Needed.pdf
Uploaded by Jessica Hull on May 19, 2026 at 7:30 AM
IMG_2026.04.27.18.00.26.jpg
Uploaded by Randall Cerone on Apr 27, 2026 at 6:10 PM
Screenshot_20260421_111940_Samsung Notes.jpg
Uploaded by Randall Cerone on Apr 21, 2026 at 11:23 AM
Signed Contract and/or Letter of Authorization
Insurance.pdf
Administrative Review-Result Letter
image011.png
image012.png
image013.jpg
Administrative Review-1-Result Letter
U2-5229 Brookdale Ithaca AL NY State Mold Remediat_260429_103543 (002).pdf
Email Confirmed No Plumbing Permit Needed.pdf
One Hard Copy & One Digital Copy of all Drawings and Specs
Proof of Insurance or Exemption Certificate CE-200
6/1/26, 8:39 AM BLD-26-53
https://ithacany.workflow.opengov.com/#/explore/records/40448/form 12/17
Record Activity
randy@venture-gc.com started a draft Record 04/17/2026 at 11:24 am
Randall Cerone added file Screenshot_20260421_111940_Samsung Notes.jpg 04/21/2026 at 11:23 am
Randall Cerone added file Screenshot_20260421_112408_Gmail.jpg 04/21/2026 at 11:24 am
Randall Cerone submitted Record BLD-26-53 04/21/2026 at 11:24 am
OpenGov system altered review step Administrative Review, changed status
from Inactive to Active on Record BLD-26-53 04/21/2026 at 11:24 am
OpenGov system altered payment step Permit Fee, changed status from
Inactive to Active on Record BLD-26-53 04/21/2026 at 11:24 am
OpenGov system assigned review step Administrative Review to Code
Enforcement Permit Email on Record BLD-26-53 04/21/2026 at 11:25 am
OpenGov system changed the deadline to Jul 20, 2026 on payment step Permit
Fee on Record BLD-26-53 04/21/2026 at 11:25 am
OpenGov system changed the deadline to May 6, 2026 on review step
Administrative Review on Record BLD-26-53 04/21/2026 at 11:25 am
OpenGov system completed payment step Permit Fee on Record BLD-26-53 04/21/2026 at 11:26 am
Code Enforcement Permit Email added file Insurance.pdf to Record BLD-26-53 04/23/2026 at 1:16 pm
Opengov System altered review step Administrative Review, changed status
from Active to On Hold on Record BLD-26-53 04/23/2026 at 1:17 pm
Code Enforcement Permit Email submitted a Change Request on Record BLD-
26-53 04/23/2026 at 1:17 pm
Randall Cerone added file IMG_2026.04.27.18.00.26.jpg to Record BLD-26-53 04/27/2026 at 6:10 pm
Randall Cerone added file image011.png to Record BLD-26-53 04/27/2026 at 6:12 pm
Randall Cerone added file image012.png to Record BLD-26-53 04/27/2026 at 6:13 pm
Randall Cerone added file image013.jpg to Record BLD-26-53 04/27/2026 at 6:13 pm
Code Enforcement Permit Email cancelled a Change Request on Record BLD-
26-53 04/28/2026 at 9:38 am
Opengov System altered review step Administrative Review, changed status
from On Hold to Active on Record BLD-26-53 04/28/2026 at 9:38 am
6/1/26, 8:39 AM BLD-26-53
https://ithacany.workflow.opengov.com/#/explore/records/40448/form 13/17
Opengov System altered review step Administrative Review, changed status
from Active to Complete on Record BLD-26-53 04/28/2026 at 9:39 am
OpenGov system altered inspection step Pre-Permit Site Inspection, changed
status from Inactive to Active on Record BLD-26-53 04/28/2026 at 9:39 am
OpenGov system altered inspection step Stream Setback Plan Review (Code
Dpt.), changed status from Inactive to Active on Record BLD-26-53 04/28/2026 at 9:39 am
OpenGov system altered inspection step Permit Plan Review (Code Dpt.),
changed status from Inactive to Active on Record BLD-26-53 04/28/2026 at 9:39 am
OpenGov system assigned inspection step Permit Plan Review (Code Dpt.) to
Jessica Hull on Record BLD-26-53 04/28/2026 at 9:39 am
OpenGov system assigned inspection step Stream Setback Plan Review (Code
Dpt.) to Jessica Hull on Record BLD-26-53 04/28/2026 at 9:39 am
OpenGov system assigned inspection step Pre-Permit Site Inspection to
Jessica Hull on Record BLD-26-53 04/28/2026 at 9:39 am
OpenGov system changed the deadline to May 12, 2026 on inspection step
Permit Plan Review (Code Dpt.) on Record BLD-26-53 04/28/2026 at 9:39 am
OpenGov system changed the deadline to May 12, 2026 on inspection step
Stream Setback Plan Review (Code Dpt.) on Record BLD-26-53 04/28/2026 at 9:39 am
Jessica Hull altered inspection step Stream Setback Plan Review (Code Dpt.),
changed status from Active to Complete on Record BLD-26-53 04/29/2026 at 2:26 pm
Jessica Hull altered inspection step Pre-Permit Site Inspection, changed status
from Active to Complete on Record BLD-26-53 04/29/2026 at 2:29 pm
Jessica Hull added file U2-5229 Brookdale Ithaca AL NY State Mold
Remediat_260429_103543 (002).pdf to Record BLD-26-53 04/29/2026 at 2:29 pm
Jessica Hull added file Email Confirmed No Plumbing Permit Needed.pdf to
Record BLD-26-53 05/19/2026 at 7:30 am
Jessica Hull altered inspection step Permit Plan Review (Code Dpt.), changed
status from Active to Complete on Record BLD-26-53 05/19/2026 at 7:31 am
OpenGov system altered approval step Complete Internal Section for Permit
Printout & Manually Issue Permit , changed status from Inactive to Active on
Record BLD-26-53
05/19/2026 at 7:31 am
OpenGov system assigned approval step Complete Internal Section for Permit
Printout & Manually Issue Permit to Jessica Hull on Record BLD-26-53 05/19/2026 at 7:31 am
Jessica Hull changed form field entry Type of Work from "Demolish" to
"Alteration" on Record BLD-26-53 05/19/2026 at 7:33 am
Jessica Hull changed form field entry Building Name from "Brookdale Ithaca" to
"Brookdale Ithaca 103C" on Record BLD-26-53 05/19/2026 at 7:34 am
Jessica Hull changed form field entry Date Permit Issued (Permit) from "" to
"05/19/2026" on Record BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull changed form field entry Inspector Assigned: from "" to "Jessica
Hull" on Record BLD-26-53 05/19/2026 at 7:42 am
6/1/26, 8:39 AM BLD-26-53
https://ithacany.workflow.opengov.com/#/explore/records/40448/form 14/17
Jessica Hull changed form field entry 3. Inspection from "" to "FINAL" on Record
BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull changed form field entry 2. Inspection from "" to "FRAMING" on
Record BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull changed form field entry 1. Inspection from "" to "DEMOLITION" on
Record BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull changed form field entry How many years is the permit? from "" to "1
year" on Record BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull changed form field entry Is Engineering Dept approval required?
from "" to "No" on Record BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull changed form field entry Is Planning Dept approval required? from ""
to "No" on Record BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull changed form field entry Is there more than one NYS Use
Occupancy class? from "" to "No" on Record BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull changed form field entry NYS Use Occupancy Classification (Permit
& CO) from "" to "I2 - Institutional" on Record BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull changed form field entry Is a sprinkler present? (Permit & CO) from
"" to "Yes" on Record BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull changed form field entry Is a sprinkler required by building code?
(CO) from "" to "Yes" on Record BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull changed form field entry Type of Construction (Permit & CO) from
"" to "V-B" on Record BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull changed form field entry Permit Type from "" to "Institutional
Renovation/Alteration" on Record BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull changed form field entry Permit Extension Requested from "" to "No"
on Record BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull changed form field entry Number of Inspections to be Displayed on
Permit (1-28) from "" to "3" on Record BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull changed form field entry Scope of Work (P)/Description (CO) from
"" to "Building 103C – Repair water-damaged wal..." on Record BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull changed form field entry Code Officer Name Printed on Document
from "" to "Jessica Hull" on Record BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull changed form field entry Zoning Use (Permit & CO) from "" to
"PDZ10" on Record BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull changed form field entry Tax Parcel Number (Permit & CO) from ""
to "27.-1-11.3" on Record BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull approved approval step Complete Internal Section for Permit
Printout & Manually Issue Permit on Record BLD-26-53 05/19/2026 at 7:42 am
OpenGov system altered inspection step Framing Inspection, changed status
from Inactive to Active on Record BLD-26-53 05/19/2026 at 7:42 am
OpenGov system altered inspection step Final Inspection, changed status from
Inactive to Active on Record BLD-26-53 05/19/2026 at 7:42 am
6/1/26, 8:39 AM BLD-26-53
https://ithacany.workflow.opengov.com/#/explore/records/40448/form 15/17
OpenGov system altered inspection step Demolition Inspection, changed status
from Inactive to Active on Record BLD-26-53 05/19/2026 at 7:42 am
OpenGov system altered inspection step Ithaca Energy Code Supplement
Inspection , changed status from Inactive to Active on Record BLD-26-53 05/19/2026 at 7:42 am
OpenGov system assigned inspection step Ithaca Energy Code Supplement
Inspection to Jessica Hull on Record BLD-26-53 05/19/2026 at 7:42 am
OpenGov system assigned inspection step Demolition Inspection to Jessica Hull
on Record BLD-26-53 05/19/2026 at 7:42 am
OpenGov system assigned inspection step Final Inspection to Jessica Hull on
Record BLD-26-53 05/19/2026 at 7:42 am
Jessica Hull assigned inspection step Framing Inspection to Jessica Hull on
Record BLD-26-53 05/19/2026 at 7:43 am
Jessica Hull removed inspection step Ithaca Energy Code Supplement
Inspection from Record BLD-26-53 05/19/2026 at 7:44 am
Jessica Hull added document step Permit to Record BLD-26-53 05/19/2026 at 7:44 am
Jessica Hull altered Record BLD-26-53, changed Expiration Date from "" to May
19, 2027 05/19/2026 at 7:44 am
Timeline
Label Activated Completed Assignee Due
Date Status
Permit Fee 4/21/2026,
11:24:58 AM
4/21/2026,
11:26:23 AM
Randall
Cerone 7/20/2026 Completed
Administrative
Review
4/21/2026,
11:24:58 AM
4/28/2026,
9:39:05 AM
Code
Enforcement
Permit Email
5/6/2026 Completed
Permit Plan
Review (Code Dpt.)
4/28/2026,
9:39:08 AM
5/19/2026,
7:31:05 AM Jessica Hull 5/12/2026 Completed
Stream Setback
Plan Review (Code
Dpt.)
4/28/2026,
9:39:08 AM
4/29/2026,
2:26:17 PM Jessica Hull 5/12/2026 Completed
Pre-Permit Site
Inspection
4/28/2026,
9:39:08 AM
4/29/2026,
2:29:07 PM Jessica Hull -Completed
Complete Internal
Section for Permit
Printout & Manually
Issue Permit
5/19/2026,
7:31:06 AM
5/19/2026,
7:42:53 AM Jessica Hull -Completed
Permit 5/19/2026,
7:44:31 AM
5/19/2026,
7:44:31 AM --Completed
6/1/26, 8:39 AM BLD-26-53
https://ithacany.workflow.opengov.com/#/explore/records/40448/form 16/17
Label Activated Completed Assignee Due
Date Status
Demolition
Inspection
5/19/2026,
7:42:54 AM -Jessica Hull -Active
Framing
Inspection
5/19/2026,
7:42:54 AM -Jessica Hull -Active
Ithaca Energy
Code Supplement
Inspection
5/19/2026,
7:42:54 AM -Jessica Hull -Active
Final Inspection 5/19/2026,
7:42:54 AM -Jessica Hull -Active
Building COO
Sign-off ----Inactive
Complete section
on form for CO/CC
printout
----Inactive
Certificate of
Occupancy Issuance ----Inactive
Archival Review &
Approval ----Inactive
6/1/26, 8:39 AM BLD-26-53
https://ithacany.workflow.opengov.com/#/explore/records/40448/form 17/17