Fillable LIC2: License Application (City of New York)

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LIC2: License Application (City of New York)

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Rev. 09/18
LIC2: License Application
Application must be typewritten.
License Number Section is used for: Changes, Renewals, and Reissues
4 Applicant Information Required for all applications.
First Name: Middle Initial: Last Name:
Home Address: Home Telephone:
City: State: Zip: Mobile Telephone:
Date of Birth (m/d/yy)
*Social Security No.:
E-Mail:
Business Name Bus. E-mail:
Office Address: Bus. Phone:
City: State: Zip:
5a Primary Business Information
8 Partner or Officer Information (must list all partners or officers)
Name:
Address: Phone:
City: State: Zip:
Lic No: % Control:
Title(s):
Name:
Address: Phone:
City: State: Zip:
Lic No: % Control:
Title(s):
Name:
Address: Phone:
City: State: Zip:
Lic No: % Control:
Title(s):
Name:
Address: Phone:
City: State: Zip:
Lic No: % Control:
Title(s):
3 License Type
New Renewal Reissue (Lost/Stolen) Change (ie: Address/Business/Deactivations)
Reinstatement
1 Application Type
2 License Number
Business Name Bus. E-mail:
Office Address: Bus. Phone:
City: State: Zip:
5b Secondary Business Information (if applicable)
Choose One:
Individual/Sole-Proprietor
On Behalf of a Corporation
On Behalf of a Partnership
On Behalf of a City Agency
7
City Employee?
Yes No
6 License Use
*Social Security Number is required for new applicants only
Elevator Inspector Elevator Co-Director Rigger Master Special Tower Concrete Safety Manager
Engineer Stationary Portable Sign Hanger Master Special Construction Superintendent
Hoisting Machine Operator
A B C
Site Safety Manager Coordinator
Master Plumber Welder
Oil Burning Equipment Installer
A B
Master Fire Suppression Piping Contractor
A B C
9 Licensing History
Yes
No Do you currently have a valid driver’s license? State where issued _________________ License# __________________
Yes
No
Have any licenses or privileges granted to you or your associated business(es) by the Department of Buildings or any other
government entity ever been rescinded, revoked, surrendered or suspended or have you or your related business(es) ever
been disqualified from performing inspections ?
If Yes, please indicate in Section 10 the type of license / certification / registration along with the reason for suspension, restriction, surrender,
revocation, or disciplinary action.
List all licenses, certifications, or registrations issued to you, by any City or State.
TYPE LIC./CERT. /REG. NUMBER CURRENT STATUS
EXPIRATION DATE NAME
Rev. 09/18
LIC2: License Application
Application must be typewritten.
License Number Section is used for: Changes, Renewals, and Reissues
As a condition of being granted a license, I attest that I comply with all New York City Administrative Code and Department rules, regulations, and directives governing how licensees conduct
their specific trade. I understand 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 my actions undertaken in connection with my license, I understand that the Administrative Code requires that I cooperate with any investigation and that failure to do so may result
in immediate suspension, revocation or other disciplinary action.
12 Statements and Signatures
11 Convictions and Fines If you answer ‘Yes’ to either of these questions, you must complete and attach form LIC34.
Yes No Have you ever been convicted or pled guilty to an offense anywhere (an offense is defined as a violation, misdemeanor or felony)?
Yes No Do you owe any penalties or fines to the City of New York?
Yes 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?
Name (print) Notarization
State of New York, County of:
Notary Seal
Signature Sworn to or affirmed under penalty of perjury
day of 20
Date Notary Signature
Fee Paid: Transaction Type:
Expiration Date: Clerk’s Signature: Date:
Internal Use Only
10 Comments
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Completed 7 November 2020

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