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FOR OFFICE USE ONLY Date Issued: License No. ELEVATOR LICENSE APPLICATION Corporation: Address: City: State: Zip: Phone: ( ) E-Mail: 1. Individuals Name: Address: City: State: Zip: Phone: ( ) Name: Address: City: State: Zip: Phone: ( ) Name: Address: City: State: Zip: Phone: ( ) Name: Address: City: State: Zip: Phone: ( ) 2. Year(s) engaged in business: 3. Are you familiar with NYS Uniform Fire Prevention & Building Code Part 1062, RS 60, Part 1250.3? Yes No LICENSE TYPE ( ) Inspector ( ) Installer ( ) Limited Installer ( ) New License ( ) Renewal ---PAGE BREAK--- 4. Do you qualify under the current ANSI/ASME QEI Standard for the Qualification of Elevator Inspectors or other relevant criteria? Yes No If yes, please fill in information below and attach a copy of your latest card: Name Date Issued Certificate # Expiration Date 5. Approximate number of persons to be employed: 6. Proof of Compensation covering employees and Disability Insurance, General Liability, Personal Injury & Property Damage Insurance: Attached hereto and forming a part of the application herein are Certificates of Insurance specifying the following insurance coverage: Workmen’s Compensation Disability Insurance General Comprehensive Liability Amount of Coverage a. Personal Injury $ b. Property Damage $ 7. Has any license previously issued to applicant by the City of Albany been denied, suspended or revoked? No Yes If yes, give date and reason for such denial, suspension or revocation: 8. Have you ever been convicted of a crime? Yes No 9. Are you presently licensed by any other municipality in New York State? No Yes If yes, which one(s) I, hereby apply to the Department of Buildings & Regulatory Compliance of the City of Albany for a license pursuant to Ordinance Number 60.121.98, Chapter 175 (Elevators) of the Code of the City of Albany to engage in business of installation, inspection and servicing of elevators. Signature Subscribed and sworn to before me this day of Notary Public/Commissioner of Deeds