PHYSICAL EXAMINATION FORM - New York City

1 LIC-62 10/2017 Page 1 PHYSICAL EXAMINATION FORM This form must be completed within 90 days prior to submission *In accordance with Federal and State Laws, the New york city Department of Buildings requires that all applicants for licenses/license holders provide their Social Security Number (SSN). DOB will use the SSN to conduct background investigations and maintain accurate license and related records. This information may be shared with other government agencies, consistent with applicable laws and Departmental policy or with the SSN holder s written permission, but will otherwise be kept confidential. The specific statutory authority for requiring SSN s is in the following: Federal Law-Privacy Act of 1974 1 Applicant Information First Name Last Name Date of Birth *Social Security # Home Address Phone Number city State Zip License Type: License Number (if, licensed) 2 Physician TO BE FILLED IN BY EXAMINING PHYSICIAN (Please print) 3 General Health Assessment Fitness is being physically and mentally capable of undertaking the tasks that an individual is required to carry out and is licensed to engage in by the NYC Department of Buildings.

2 Mentally capable means to lack any medical conditions that might impair cognitive function or emotional state to the extent that the applicant cannot complete the responsibilities of the license. Medically fit applicants must not be suffering from medical conditions or undergoing any medical treatment that is likely to cause sudden loss of consciousness or incapacity, impairment of awareness, concentration, or significant limitation of mobility that could prevent the licensee from performing the duties of the license. See page 2 for licensee duties, as per the NYC Administrative Code. Name of Physician Address of Physician city State Zip Physician s Signature Date _____ _____ Physician s Clearance TO BE FILLED IN BY EXAMINING PHYSICIAN (Please print) I certify that I have examined: with the knowledge of his/her duties, I find him/ her qualified under the regulations.

3 (see addendum) Please choose one: Medically fit Medically fit with accommodations - (Please attach Accommodation Statement ) Not medically fit A complete EXAMINATION form for this person is on file in my office: Address of EXAMINATION Date of EXAMINATION Name of Physician Signature of Physician Physician s Stamp: I, as an applicant, authorize the re-lease to my the licensing authority of all information contained on this EXAMINATION form and all other forms generated as a direct result of my EXAMINATION . Name of Applicant Signature of Applicant LIC62 10/2017 PHYSICAL EXAMINATION FORM (CONT D) Page 2 Addendum: License Regulations License Type Relevant Regulations Welder This license authorizes a NYC licensee to perform manual welding work on any structural member of any build-ing in the city . NYC Administrative Code Section 28-407; Title 1 of the Rules of the city of New york Section 104-11 Site Safety Manager; Site Safety Coordinator This license authorizes a NYC licensee to ensure construction site compliance with the site safety plan and all safety requirements, as specified in chapter 33 of the New york city Building Code.

4 NYC Administrative Code Section 28-402; NYC Administrative Code Section 28-403 Private Elevator Inspection Agency Inspector; Private Elevator Inspec-tion Agency Director This license authorizes a NYC licensee to perform and/or witness Elevator inspections and tests or enter into contracts pursuant to article 304, chapter 3 of the NYC Administrative Code. NYC Administrative Code Section 28-421; NYC Administrative Code Section 28-422 Sign Hanger This license authorizes a NYC licensee to hoist lower or to hang or attach a sign, upon or on the outside of any building or structure in the city . This may include the use of cranes or suspended scaffolds. NYC Administrative Code Section 28-415 High Pressure Boiler Operating Engineer This license authorizes a NYC licensee to operate any high-pressure boiler in the city of New york . Excluding the exceptions listed in NYC Administrative Code. NYC Administrative Code Section 28-413 Oil Burning Equipment Installer Authorizes installation of any type of oil-burning equipment in the city , as an independent contractor with full re-sponsibility for the manner in which the work is done, for the materials and equipment used, and for the control and direct and continuing supervision of the persons employed on the work.

5 Such equipment shall include but not be limited to burners, boilers and generators. NYC Administrative Code Section 28-412 Master Plumber This license authorizes a NYC licensee to perform and supervise plumbing work, including the installation, maintenance, repair, modification, extension, or alteration of plumbing and related systems, as prescribed in the NYC Administrative Code. NYC Administrative Code Section 28-408; Electrician Master/Special Electrician: This license authorizes a NYC licensee to perform and supervise the installation, alteration, maintenance or repair of electric wires and wiring apparatus and other appliances used or to be used for the transmission of electricity for electric light, heat, power, signaling, communication, alarm or data transmis-sion. NYC Administrative Code Section 27-3004; NYC Administrative Code Section 27-3017 Master Fire Suppression Piping Contractor This license authorizes a NYC licensee to perform and supervise fire suppression work, including the installation, maintenance, repair, modification, extension, or alteration or testing of a fire suppression piping system, as pre-scribed in the NYC Administrative Code.

6 NYC Administrative Code Section 28-410; Concrete Safety Manager This license authorizes the a NYC licensee to oversee concrete operations and related job site safety, as speci-fied in chapter 33 of the New york city Building Code. Building Code Section ; Title 1 of the Rules of the city of New york Section 3310-02 Construction Superintendent This license authorizes the NYC licensee to maintain job site safety and ensure compliance with plans in accord-ance with Chapter 33 of the NYC Building Code and as specified in Title 1 of the Rules of the city of New york Section 3301-02