Get NY LIC2 2016

LIC2 License Application Application must be typewritten. License Number Section is used for Changes Renewals and Reissues. 1 Application Type New Renewal Reissue Lost/Stolen Change ie Address/Business/Deactivations 3 License Type Elevator Inspector Elevator Co-Director Engineer Stationary Portable Hoisting Machine Operator Class Master Plumber Oil Burning Equipment Installer Rigger Master Special Sign Hanger Site Safety Manager Coordinator Welder Master Fire Suppression Piping Contractor Tower 4 Applicant Information Required for all applications. First Name Middle Initial Last Name Home Address Home Telephone City State Date of Birth m/d/yy Zip Mobile Telephone Social Security No* E-Mail 5a Primary Business Information 6 License Use Business Name Bus. E-mail Choose One Office Address Bus. Phone Individual/Sole-Proprietor On Behalf of a Corporation On Behalf of a Partnership 5b Secondary Business Information if applicable On Behalf of a City Agency 7 City Employee Yes No 8 Partner or Officer Information must list all partners or officers Name Address Lic No Control Phone Title s 9 Convictions and Fines If you answer Yes to either of these questions you must complete and attach form LIC34. No Have you ever been convicted or pled guilty to an offense anywhere an offense is defined as a violation misdemeanor or felony No Do you owe any penalties or fines to the City of New York 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 10 Statements and Signatures 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* Name print Notarization State of New York County of Signature Sworn to or affirmed under penalty of perjury day of Date Notary Seal Notary Signature Internal Use Only Fee Paid Transaction Type Expiration Date Clerk s Signature Rev 10/16. 1 Application Type New Renewal Reissue Lost/Stolen Change ie Address/Business/Deactivations 3 License Type Elevator Inspector Elevator Co-Director Engineer Stationary Portable Hoisting Machine Operator Class Master Plumber Oil Burning Equipment Installer Rigger Master Special Sign Hanger Site Safety Manager Coordinator Welder Master Fire Suppression Piping Contractor Tower 4 Applicant Information Required for all applications. First Name Middle Initial Last Name Home Address Home Telephone City State Date of Birth m/d/yy Zip Mobile Telephone Social Security No* E-Mail 5a Primary Business Information 6 License Use Business Name Bus. .