LIC2: NYC License Application

Under 1. APPLICATION TYPE, mark New, Renewal, Reissue (Lost/Stolen), Change (i.e. Address/Business/Deactivation) or Reinstatement.

Enter the License No. under 2. LICENSE NUMBER.

The License Number section is used for changes, renewals, and Reissues.

Under 3. LICENSE TYPE, mark Elevator, Engineer, Hoisting Machine Operator, Master Plumber, Master Fire Suppression Piping Contractor, Concrete Safety Manager, Construction Superintendent, Oil Burning Equipment Installer, Rigger, Sign Hanger or Site Safety.

Under Elevator, the form lists Director, Co-Director, Inspector, Technician, Limited Technician and Helper.

4. APPLICANT INFORMATION is required for all applications: enter Last Name, First Name, MI, Social Security No., Date of Birth (MM/DD/YYYY), Home Address, Email Address, City, State, Zip Code, Home Phone No. and Mobile Phone No.

5A. PRIMARY BUSINESS INFORMATION is required for all applications: enter Business Name, Business Address, City, State, Zip, Email and Business Phone.

For 6. LICENSE USE (choose one), mark Individual/Sole-Proprietor, on behalf of a Corporation, on behalf of a Partnership or on behalf of a City Agency.

5B. SECONDARY BUSINESS INFORMATION: Business Name, Business Address, City, State, Zip, Email and Business Phone.

For 7. CITY EMPLOYEE?, mark Yes or No.

8. PARTNER & OFFICER INFORMATION: you must list all partners or officers.

For each partner or officer, enter Name, Phone No., License No., % Control, Title(s), Address, City, State and Zip.

9. LICENSING HISTORY: List all licenses, certifications, or registrations issued to you, by any City or State, with the NAME, TYPE, LIC/CERT/REGISTRATION NO., CURRENT STATUS and EXPIRATION DATE of each.

Mark Yes or No for Do you have a valid driver's license? and enter the Driver's License No. and State.

If Yes to any of the following two questions, indicate the type of license/certification/registration with additional details in Section 10 COMMENTS.

Have any licenses or privileges granted to you or your associated business(es) by the NYC Department of Buildings or any other government entity ever been rescinded, revoked, surrendered, suspended, otherwise disciplined, or have you or your related business(es) ever been disqualified from performing inspections? Mark Yes or No.

Have any license application(s) ever been denied to you by DOB or any other government entity? Mark Yes or No.

In 11. CONVICTIONS & FINES, if you answer Yes to any of these questions, you must complete and attach form LIC34.

Have you ever been convicted or pled guilty to an offense anywhere (an offense is defined as a violation, misdemeanor or felony)? For renewal applicants, were you convicted since your last renewal? Mark Yes or No.

Do you owe any penalties to the City of New York? Mark Yes or No.

Does any company or business you have been associated with under your Department-issued license owe any fines, penalties or fees to the City of New York that were incurred during your association with that company or business? Mark Yes or No.

In 12. STATEMENTS & SIGNATURES, as a condition of being granted a license, you attest that you comply with all New York City Administrative Code and Department rules, regulations, and directives governing how licensees conduct their specific trade.

It is unlawful to make a false statement to the Department; or 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.

Such actions are punishable by imprisonment, fine and/or loss of license.

In the event of an accident that involves your actions undertaken in connection with your license, the Administrative Code requires that you cooperate with any investigation and failure to do so may result in immediate suspension, revocation or other disciplinary action.

Notarization has State of New York, County of:, Sworn to or affirmed under penalty of perjury, Date, Notary Signature and Notary Seal.

Print your Name and add your Signature. Notarization has a Notary Signature and a Notary Seal.