AUTHENTICATION FORM

Instructions:
In order to participate in Buildings' electronic filing program, you must accurately complete this form. Please sign the form, have it notarized, and stamp it with your professional seal (if applicable). Any false or misleading statement(s) provided herein will result in the applicant's disqualification from being able to renew permits electronically and may lead to criminal prosecution.


APPLICANT INFORMATION
Primary E-mail Address:
Date:10/2/2023
Secondary E-mail Address:   
Last Name:
First Name:
Business Address:
City:
State:
Zip:
Contact Tel:--
Mobile Phone:--

LICENSES AND TRACKING NUMBERS
Please list all licenses and tracking numbers issued to you by DOB and associated business information
Concrete Test Lab Director / Safety Manager License Number:      
Company Name:      
Construction Superintendent License Number:      
Business Name:      
Electrical Contractor License Number:      
Business Name:      
Filing Representative DOB Issued ID #      
Business Name:      
General Contractor Tracking Number:      
Business Name:      
High Pressure Boiler Operator/Stationary Engineer License Number:      
Business Name:      
Hoist Machine Operator License Number:      
Business Name:      
Master Fire Suppression &
Piping Contractor
License Number:      
Business Name:      
Master
Plumber
License Number:      
Business Name:      
Master Rigger License Number:      
Business Name:      
NYS Boiler Inspection Certificate Number:      
Business Name:      
NYS Professional Engineer License Number:      
Business Name:      
NYS Registered Architect License Number:      
Business Name:      
NYS Registered Landscape Architect License Number:      
Business Name:      
Oil Burner
Installer
License Number:      
Business Name:      
Sign
Hanger
License Number:      
Business Name:      
Site Safety (Manager, Coordinator) License Number:      
Business Name:      
Tower Crane Rigger License Number:      
Business Name:      

STATEMENT OF AGREEMENT

As a condition of being registered to participate in the electronic permit program, I hereby agree to comply with all relevant laws, rules, regulations and policies and directives, including the NYC Administrative Code, Rules of the City of New York, and the Departmentís rules, regulations, policy and procedure notices, directives, and bulletins. I understand that (a) I will be issued a User ID and Password by the Department for use of the eFiling system, (b) the User ID and Password are for use by me only, and (c) I may only use the User ID and Password to apply for and renew permits for which my name appears as the original applicant and for which I will perform the work in compliance with the relevant provisions of the law, rules, regulations, policies and directives mentioned above.

I understand that I will be receiving emails and/or other correspondence from the Department, with listings of my applications and/or permits. I understand that I am obligated to review such correspondence and must contact the Department within five business days of receiving this information if any application was improperly or illegitimately filed under my license number. I also understand that failure to notify the Department within that time shall be considered presumptive acceptance of and responsibility for those applications and the work performed under those permits.

I understand that it is a crime to offer or give to a city employee, or for a city employee to accept, any benefit, monetary or otherwise, either as a gratuity for properly performing the job or in exchange for special consideration. A conviction of offering of a bribe or gratuity is punishable by imprisonment, fine or both.

Additionally, I understand that failure to adhere to this agreement may result in disciplinary action against my license, up to and including possible revocation of my license and/or criminal prosecution.

I understand that knowing falsification of any statement in this document is a misdemeanor and is punishable by a fine, imprisonment, or both, under the NYC Administrative Code, and the New York State Penal Law. I have read and understand all the information contained herein. I have provided full and complete information in answer to each question and all information I have supplied is true and accurate to the best of my knowledge.


________________________________ ________________
Signature Date





Notarization (If applicable, See instructions below)
State of New York, County of __________________________
Sworn to or affirmed under penalty of perjury:

________________________________ ________________
Notary Signature Date

Apply
Licensee Seal(s)
(If applicable, See instructions below)




Apply
Notary Seal

Instructions:

Please follow the instructions for your license type below. If you have several license types on your eFiling Authentication Form, you should print a copy of the form for each license type and follow the instructions for each license type separately.

Concrete Test Lab Director, Electrical Contractor, Master Fire Suppression & Piping Contractor, Master Plumber, Oil Burner Installer, Professional Engineer, Registered Architect and Registered Landscape Architect:

Your license information will be verified and you will be notified by email when your account is activated. Once you are approved, you can then use your eFiling email and password in eFiling or DOB NOW.

For each filing that you submit in DOB NOW: Build or DOB NOW: Safety, you will also have to upload a completed Design Professional/Licensee Seal and Signature form (DPL-1 form).

Concrete Safety Manager, Construction Superintendent, Filing Representative, General Contractor, High Pressure Boiler Operator/Stationary Engineer, Hoist Machine Operator, Master Rigger, Sign Hanger, Site Safety Manager or Tower Crane Rigger:

Your license information will be verified and you will be notified by email when your account is activated. Once you are approved, you can then use your eFiling email and password in eFiling or DOB NOW.

Boiler Insurance Agency Inspector:

The Boilers Unit will verify your licensing information and then notify you that your account has been activated. Once you are approved, you can then use your eFiling email and password at DOB NOW.

Thank you!