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New Renewal Date Commercial Inspector’s License Application Corporation Date Incorporated Address City State Zip Code Phone ( ) 1. Individuals: Name Address City State Zip Code Phone ( ) Name Address City State Zip Code Phone ( ) Name Address City State Zip Code Phone ( ) Name Address City State Zip Code Phone ( ) 2. Year(s) engaged in business 3. Are you familiar with NYS Uniform Fire Prevention & Building Code? Yes No 4. Do you qualify under the current NYS Code Enforcement Officer Certification? Yes No If yes, please fill in information below and attach a copy of your previous and current year’s CEO continuing education credits: Name Date Certified Certificate # 5. Approximate number of persons to be employed ---PAGE BREAK--- 6. Proof of Compensation covering employees and Disability Insurance, General Liability, Personal Injury and 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 General Comprehensive Liability Amount of Coverage Disability Insurance 1. Personal Injury $ 2. 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) 10. I, hereby apply to the Department of Buildings and Regulatory Compliance of the City of Albany for a License pursuant to Chapter 151 (Commercial Standards) of the Code of the City of Albany to engage in business of Inspection and Certification of Public Assembly Spaces. Signature Subscribed and sworn to before me this day of Notary Public/Commissioner of Deeds For Office Use Only Approved Disapproved Date License #