Application Form For Certificate Of Attestation Of Exemption (Page 2 of 4) in pdf

Application Form For Certificate Of Attestation Of Exemption Page 2

4. Permit/License/Contract Information:

A. Nature of Business:(please check only one)

 Construction/Carpentry

 Electrical

 Demolition

 Landscaping

 Plumbing

 Farm

 Restaurant / Food Service

 Trucking / Hauling

 Food CartVendor

 Horse Trainer/Owner

 Homeowner

 Hotel / Motel

 Bar / Tavern

 Mobile - Home Park

 Other (please explain) ______________________________________________________________

B. Applying for:

 License (list type) __________________________________________________________________

 Permit (list type) ___________________________________________________________________

 Contract with Government Agency

Issuing Government Agency: _____________________________________________________________

(e.g. New York City Building Department, Ulster County Health Department, New York State

Department of Labor, etc.)

5. Job Site Location Information: (Required if applying for a building, plumbing, or electrical permit)

A. Job Site Address

Street address________________________________________________________________________

City: _________________________ State: ___________ Zip: ________County: ________________

B. Dates of project: (mm/dd/yyyy) ___________________ to:(mm/dd/yyyy) _________________________

Estimated Dollar amount of project:

 $0 - $10,000

 $50,001 - $100,000

 10,001- $25,000

 Over $100,000

 $25,001 - $50,000

6. Partners/Members/Corporate Officers -must list all with titles except for limited partnerships which

must include only general partners. Sole proprietors can skip this section.

Name: ________________________________________ Title: _____________________________________

(Attach additional sheet if necessary)

CE-200APPLY (2/2009)

- 2 -

Application Form For Certificate Of Attestation Of Exemption Page 2