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Special Inspection Agency Registration Form
 
In order to apply for Special Inspection Agency Registration, please provide the following information. Items with a (*) are required.

EMAIL CONTACT INFORMATION
Email Address (*) Re-Enter Email Address (*)

AGENCY INFORMATION
Agency Name (*) 
Owner First Name (*)     Owner Last Name (*) 
Telephone (*)     Fax 
Agency Address
House Number (*)     Street Name (*) 
City (*)  State (*)  Zip (*) 

DIRECTOR INFORMATION
License Type (*)     License No (*) 
Title (*)   
First Name (*)  M. I.  Last Name (*) 
Home Address
House Number (*)     Street Name (*) 
City (*)  State (*)  Zip (*) 
Home Phone (*)     Mobile Phone 
Date of Birth (*)     E-mail 

INSURANCE INFORMATION
Liability
Company (*)     Expire Date (*) 
Policy No (*) 
Workers Compensation
Company (*)     Expire Date (*) 
Policy No (*)     Waived (*) Yes No

LICENSE USE
License use (*)   

TECHNICAL DIRECTOR INFORMATION required when selecting 'Corporation' or 'Partnership' for LICENSE USE
First Name     Last Name 
Title       
License Type     License No 
First Name     Last Name 
Title       
License Type     License No 
First Name     Last Name 
Title       
License Type     License No 
First Name     Last Name 
Title       
License Type     License No 

SPECIAL INSPECTIONS (*)
FLOOD ZONE COMPLIANCE FUEL-OIL STORAGE AND FUEL-OIL PIPING SYSTEMS
LUMINOUS EGRESS PATH MARKINGS HIGH-PRESSURE STEAM PIPING (WELDING)
EMERGENCY & STANDBY POWER SYSTEMS (GENERATORS) FUEL-GAS PIPING (WELDING)
STRUCTURAL STEEL - WELDING STRUCTURAL STABILITY - EXISTING BUILDINGS
STRUCTURAL STEEL - HIGH STRENGTH BOLTING MECHANICAL DEMOLITION
STRUCTURAL COLD-FORMED STEEL EXCAVATION - SHEETING, SHORING, AND BRACING
CONCRETE - CAST-IN-PLACE SOIL PERC. TEST-STORM WATER SYSTEM (DRYWELL)
CONCRETE - PRECAST SOIL PERC. TEST-INDIVID ON-SITE PRIVATE SEWAGE DISP.(SEPTIC)
CONCRETE - PRESTRESSED ON-SITE STORM WATER DRAIN. DISP. /DETENT INSTALL (DRYWELL)
MASONRY INDIVIDUAL ON-SITE PRIVATE SEWAGE DISP INSTALL (SEPTIC)
WOOD - INSTALLATION OF HIGH-LOAD DIAPHRAGMS SPRINKLER SYSTEMS
WOOD - INSTALLATION OF METAL-PLATE-CONNECTED TRUSSES STANDPIPE SYSTEMS
WOOD - INSTALLATION OF PREFABRICATED I-JOISTS HEATING SYSTEMS
SUBGRADE INSP / SOILS-SITE PREP CHIMNEYS
SUBSURFACE / SOILS-FILL PLACEMENT IN-PLACE DENSITY FIRE-RESISTANT PENETRATIONS AND JOINTS (FIRESTOP)
SUBSURFACE / SOILS INVESTIGATION (BORINGS/TEST PITS) ALUMINUM WELDING
DEEP FOUNDATIONS / PILES SEISMIC ISOLATION SYSTEMS
VERTICAL MASONRY FOUNDATION ELEMENTS/PIERS RAISING AND MOVING OF A BUILDING
UNDERPINNING STRUCTURAL STEEL - DETAILS
WALL PANELS, CURTAIN WALLS, AND VENEERS HELICAL PILES
SPRAYED FIRE-RESISTANT MATERIALS MASTIC AND INTUMESCENT FIRE-RESISTANT COATINGS
EXTERIOR INSULATION AND FINISH SYSTEMS (EIFS) HIGH TEMPERATURE HOT WATER PIPING (WELDING)
SMOKE CONTROL SYSTEMS POST-INSTALLED ANCHORS
MECHANICAL SYSTEMS  

CONVICTIONS AND FINES If you answer "Yes" to either of these questions, you must complete and attach form LIC34.
Have you pled guilty to or been convicted of any crime (misdemeanor or felony)? (*)
Yes No
Do you owe any penalties or fines to the city of New York? (*)
Yes No
Does any company or business you have been associated with under your Department-issued license owe any penalties of fines to the city of New York? (*)
Yes No