Fillable Pw2: Work Permit Application - New York (Page 3 of 3) in pdf

PW2

PAGE 3

9 Concrete Information

Choose and complete any appropriate sub-choices.

Are you requesting to exclude concrete work at

Does your approved work include 2,000 cubic

Yes

this time from this permit? If no, 9B

yards or more of concrete? If yes, 10 and 11

10 Concrete Subcontractor

Required if applicable. (* Indicates optional.)

Yes

Is the applicant/contractor named in section four performing the concrete 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 Concrete Subcontractor as set forth in the

Department of Buildings rules and regulations.

Name (print)

Notarization

Notary Seal

State of New York, County of:

Sworn to or affirmed under penalty of perjury

Signature

day of

Date

Notary Signature

11 Concrete Safety Manager

Required if applicable. (* Indicates optional.)

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 Concrete 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:

Sworn to or affirmed under penalty of perjury

Signature

day of

Date

Notary Signature

12 Applicant / Contractor Statements and Signatures

Required for all applications.

The information in this application is correct and complete to the best of my knowledge and I assume responsibility for all statements on this form. I understand that if

I am found after hearing to have knowingly or negligently made a false statement on this or any other document submitted to the Department, I may be subject to fine,

imprisonment, and/or barred from filing further documents with the Department. 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.

I will comply with all applicable laws, rules and regulations including all insurance requirements, and, in addition.

 I hereby state if a Construction Superintendent, Site Safety Coordinator, Site Safety Manager, Demolition Subcontractor, Concrete Subcontractor, or Concrete

Safety Manager is required for this application I have hereby advised the individual listed herein he or she is designated as such and hereby certify he or she is

registered and in good standing with the NYC Department of Buildings.

 I hereby state this renewal application with no change to Applicant, Filing Representative, Construction Superintendent, Site Safety Coordinator, Site Safety

Manager, Subcontractors, Concrete Safety Manager or insurance is for the work as originally filed or as officially amended.

 In accordance with §28-104.8 of the Administrative Code, I hereby declare I am authorized by the owner of the above-referenced premises to make this

application for a permit to perform the work described herein. In accordance with Rule 101-16, I will post the permit in a conspicuous and visible location.



Check here if the work authorized by this permit does NOT require adjacent property insurance.

Name (print)

Notarization (required if not licensee)

Licensee Seal or Notary Seal

State of New York, County of:

Signature

Sworn to or affirmed under penalty of perjury

day of

Date

Notary Signature

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