Pw2: Work Permit Application - New York Page 2
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5 Filing Representative
Complete if different from applicant specified in section 3. (* Indicates optional.)
Last Name
First Name
Middle Initial
Business Name
Business Telephone
Business Address
*Business Fax
City
State
Zip
*Mobile Telephone
*E-Mail
Registration Number
6 Insurance P.E. / R.A. only
(* indicates required for all permits)
Liability Insurance
Workers’ Compensation Insurance*
Disability Insurance *
(NB permits only)
7 Construction Superintendent, Site Safety Coordinator, Site Safety Manager
Required if applicable. (* Indicates optional.)
I, the applicant / contractor, hereby declare the scope of work filed under this permit application requires: (choose one)
Construction Superintendent
Site Safety Coordinator
Site Safety Manager
Last Name
First Name
Middle Initial
Business Name
Telephone
Address
*Fax
City
State
Zip
*Mobile Telephone
*E-Mail
Registration Number
I, the undersigned, will perform, on behalf of the Contractor, all of the functions required of a Construction Superintendent, or Site Safety
Coordinator, or Site Safety Manager (identified above) as set forth in the Department of Buildings rules and regulations.
Name (print)
Notarization
Notary Seal
State of New York, County of:
Signature
Sworn to or affirmed under penalty of perjury
day of
20
Date
Notary Signature
8 Demolition Subcontractor
Required if applicable. (* Indicates optional.)
Yes
No
Is the applicant/contractor named in section four performing the demolition work for this permit? If no, complete this section.
Last Name
First Name
Middle Initial
Business Name
Telephone
Address
*Fax
City
State
Zip
*Mobile Telephone
*E-Mail
Registration Number
I, the undersigned, will perform, on behalf of the Contractor, all of the functions required of a Demolition Subcontractor as set forth in the
Department of Buildings rules and regulations.
Name (print)
Notarization
Notary Seal
State of New York, County of:
Signature
Sworn to or affirmed under penalty of perjury
day of
20
Date
Notary Signature
12/14
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