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Electrical Inspection Certification Application Inspector: New Renewal Date 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 National Electric Code? Yes No 4. Do you qualify under the current National Association of Electrical Inspectors or other relevant criteria? Yes No ---PAGE BREAK--- 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 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 certification 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 & Regulatory Compliance of the City of Albany for Certification pursuant to Standard Operating Procedure BRC-AP-30 of the City of Albany, Department of Buildings & Regulatory Compliance to engage in business of Electrical Inspections. Enclosed is my $400 annual certification fee. Signature Subscribed and sworn to before me this day of Notary Public/Commissioner of Deeds For Office Use Only Approved Disapproved Date Certification #