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Aeu 3321

This document is a Certificate of Correction and Statement in Support form regarding a Department of Buildings OATH summons for violations of NYC Building Code Sections 3321.1 and 3321.2.1. The form requires information about the summons such as the number, location of occurrence, and certifier. It also requires course provider and worker training details such as date, type of training, and course name. The certifier must then state that the worker named has received approved site safety training at no cost and without changes to employment terms. The certifier signatures and notarization are required, with a warning that false certification is a criminal offense.

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mohamed sameir
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208 views

Aeu 3321

This document is a Certificate of Correction and Statement in Support form regarding a Department of Buildings OATH summons for violations of NYC Building Code Sections 3321.1 and 3321.2.1. The form requires information about the summons such as the number, location of occurrence, and certifier. It also requires course provider and worker training details such as date, type of training, and course name. The certifier must then state that the worker named has received approved site safety training at no cost and without changes to employment terms. The certifier signatures and notarization are required, with a warning that false certification is a criminal offense.

Uploaded by

mohamed sameir
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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AEU3321:

Certificate of Correction and Statement in Support


(for Department of Buildings OATH Summonses regarding Sections 3321.1 and 3321.2.1 of the NYC Building Code)

VIOLATION AND CERTIFICATION INFORMATION


Summons Number

Place of Occurrence
(address violation issued) (Street Address, City, State, Zip Code)

I, , duly swear under penalty of perjury that I am the (check one):

Permit Holder Property Owner Employer (Sub Contractor)

My mailing address is (insert the certifier’s mailing information):


(House Number, Street Address)

(City, State, Zip Code)

COURSE PROVIDER AND WORKER INFORMATION

Course Provider Name: __________________________________________________ Date of Agreement (if applicable): ____________________

Course Provider Address (provide full address): _____________________________________________________________________________________

Worker Name (last, first): __________________________________________________ Job Title: _________________________________________

Date of Training: ____________________________ Type of SST Card: (SST, Temp SST, Limited SST, Supervisor SST)_______________________

Training Course (where applicable): OSHA 10-Hour OSHA 30-Hour 100-Hour Course Site Safety Training

STATEMENT IN SUPPORT

I, __________________________________________, hereby state that _____________________________________________________________ has:


(Print Name) (Name of Business/Individual)

Must check one:


I have paid for department approved Site Safety training to be provided by the above-listed course provider at no cost to the listed worker. For
the duration of the required Site Safety training, there have been no changes to the terms and conditions of the listed worker’s employment
including hours and rate of pay, as set forth in Section 28-204.1.1. Such worker continued/continues to be employed and paid the same wages
they had been receiving prior to the issuance of the above-referenced summons. There are no workers at the place of occurrence, as indicated
on the above-referenced summons, who have not been trained or scheduled to be trained or

Department-approved Site Safety training was completed prior to the listed worker’s current employment. Please see attached supporting
documentation. There have been no changes to the terms and conditions of the listed worker’s employment with the above -listed employer
since issuance of the above-referenced summons. There are no workers at the place of occurrence, as indicated on the above-referenced
summons, who have not been trained or scheduled to be trained or

OTHER: (please specify what actions were taken to comply with the Site Safety training requirements and attach supporting documentation)

There have been/will be no changes to the terms and conditions of the listed worker’s employment, including hours and rate of pay as set forth
in Section 28-204.1.1. For the duration of the required site safety training and, the listed worker continues to be employed and paid the same
wages they had been receiving prior to the issuance of the above-referenced summons. There are no workers at the place of occurrence,
indicated on the above referenced summons, who have not trained or scheduled to be trained.
Name (print) Notarization State of New York, County of: Notary Seal

Signature Sworn to or affirmed under penalty of perjury

day of 20

Date Notary Signature

False certification is a criminal misdemeanor under sections 28-203.1.1 and 28-211.1 of the NYC Administrative Code, punishable by up to one (1) year imprisonment and/or fine
of up to $25,000. It is also punishable with a civil penalty of up to $25,000.

FORM SUBMISSION
To submit this form, use an eFiling account to login to DOB NOW at www.nyc.gov/dobnow and select the BIS Options portal. If you need to create
an eFiling account visit www.nyc.gov/DOBNOWtips. Reminder, when submitting this form include all supporting documents.

nyc.gov/buildings Rev. 7/21

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