Pw3 Form – Fill Out and Use This PDF

Must be typewritten.

1Reason For Filing Required for all applications.

2Location Information Required for all applications.

3Cost Details Required for all applications.

Cost estimates shall include total value of work per §28-112.3 of the NYC Administrative Code and shall be direct work costs based upon material and labor; work shall include all construction elements including, but not limited to, construction equipment, wall and floor finishes, built-in cabinets, and kitchen appliances. Indirect costs, including but not limited to general conditions and insurance, shall be added to direct work costs and shall be reflected in the unit costs shown. When filing an enlargement the estimated cost should be exclusive of any work performed within the additional square footage. “Yes” or “No” must be specified for each “Category of Work” listed below.

TOTAL JOB COST: $

*List ALL Categories of Work specified “Yes” above. Use more than one line for Categories of Work that involve multiple unit costs. See PW3 Form Instructions for a sample of completed Section 3 Cost Details. For enlargements, only items associated with work performed in the existing area should be listed.

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6 Design Applicant’s Statements and Signatures

I hereby state the information on this form is correct and complete to the best of my knowledge. I understand falsification of any statement is a misdemeanor and punishable by a fine, imprison- ment, or both. I also understand 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 understand that if I am found after hearing to have knowingly or negligently made a false state- ment 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 under the provisions of this code or of a rule of any agency, I may be barred from filing further applications or documents with the Department.

P.E. / R.A. Seal (apply seal, then sign and date over seal)

7Owner’s/Lease Holder’s Statements and Signatures Notary only required when submitting to obtain Sign-off.

I hereby state the information on this form is correct and complete to the best of my knowledge. I understand falsification of any statement is a misdemeanor and is punishable by a fine or imprisonment, or both. I also understand 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 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 under the provisions of this code or of a rule of any agency, I may be barred from filing further applications or documents with the Department.

Internal Use Only

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