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Fill Out Your Sh 430 Form

The SH 430 form is an official application used to request an Asbestos Handling License in New York State. This form collects essential information about the applicant's company, including details about ownership, organizational structure, and the specific type of asbestos work to be performed. To begin the process of filling out this form, click the button below.

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Article Structure

The SH 430 form is an essential document for businesses seeking to obtain an asbestos handling license in New York State. Applicants must choose between an original license for a fee of $500 or a renewal for $300, ensuring compliance with safety standards set forth by the Division of Safety and Health. The form requests detailed information about the company, including its legal structure, Federal Employer Identification Number, and the start date of operations. A crucial component of the application involves identifying key personnel such as owners, partners, and any affiliate organizations. Furthermore, applicants must specify the type of asbestos work their organization intends to perform, such as abatement or air monitoring, and provide information regarding their designated supervisor. Critical affirmations regarding past legal issues, as well as proof of disability and workers' compensation insurance, are also required to validate the application. The firm history section probes into previous violations or legal actions that may impact eligibility. Properly completing the SH 430 form can pave the way for a licensed operation focused on asbestos management, promoting safe practices within the industry.

Sh 430 Example

Please do not write in this space.			Bates #	Lic #
Approved		Reason (If disapproved):	Check #	File #
Disapproved			Check #	File #
Disapproved	

Division of Safety and Health

License and Certification

Harriman State Office Campus

Building 12, Room 161A

Albany, NY 12240

Application for an Asbestos Handling License

1. Type of license:

Original ($500 fee)

License Number (Renewal only):

Renewal ($300 fee)

2. Name of company or organization (Company name must be exactly as registered with NYS Department of State.):

3a. Federal Employment Identification Number:

Type of organization:

Corporation

Partnership

3b.

New York State Unemployment Insurance Employer

Sole Proprietorship

Registration Number (E.R. No.):

Government

Other (Specify)

5. Incorporation

When did the company begin operations under its current name?

Mo/Day/Year

b. State

7a.

Street address:

City:

State:

Zip Code:

7b.

Mailing address, if different:

8. Duly authorized representative:

a. Name of representative:

d. Business telephone number:

b. Social Security Number:

e. Fax number:

c. Job title - (circle one): Administrator, Assistant, Director,

f. Email address:

Manager, Officer, Supervisor, Other

g. Business Mailing address of the duly authorized representative:

If “Government” is checked in item 4, Skip items 9 through 11.

SH 430 (05/18)

9.List all owners, partners and shareholders who own five percent or more of the company and all officers and directors of the company (attach additional sheets if necessary).

Name

Home address (Street, City, State, Zip)

Soc. Sec. No.

Percent ownership

Role- (select one)

Director, Officer, Owner Partner, Shareholder, Other

10. Is the company an affiliate of any other organization? Yes 	No 	If yes, list name(s) and address(es) of the
organizations (attach additional sheets if necessary).

Company name

FEIN

Address

(Street, City, State, Zip)

11.List all owners, partners and shareholders who own ten percent or more of any affiliates and all officers and directors of such affiliates (attach additional sheets if necessary).

Name

Home address (Street, City, State, Zip)

Soc. Sec. No.

Percent

ownership

Role - (select one) Director, Officer, Owner Partner, Shareholder, Other

12.Check at least one of the types of asbestos work to be performed:

Note: If you check abatement, answer Question 13. If you don’t, you must complete Question 14. Abatement

Management Planning

Project Design

Monitoring

Inspection

Air Monitoring

Other (please explain)

13.Designated Supervisor:

Name of Supervisor (if abatement is checked in question 12)

Signature of Supervisor (No co-signs or stamps):

Department of Labor Asbestos Certificate Number:

14.Affirmation statement: If abatement is not checked in question 12, place an X in the box to affirm the following statement.

The firm’s activities shall not include actual

asbestos abatement operations during the period for which the license is valid.

Affirmed

Social Security Number:

15.Firm History

You must answer either “Yes” or “No” to every question listed below. Provide details on a separate sheet.

Have you the applicant, your authorized representative, the firm, any affiliate, any predecessor company or entity, owner of 5% or more of the firm’s shares, director, officer, partner or proprietor been subject to any of the following (New applicants must provide previous 5 years and renewal applicants must provide for time since last application.):

YesNo

 

A conviction of a crime?

A Notice of Violation and/or Order to Comply, an administrative hearing or proceeding, or a determination involving a violation of the New York State Labor Law or any rule or regulation issued under the Labor Law?

		A citation, an administrative hearing or proceeding, or a determination involving a violation of Local
		Laws 70 and 76, and the asbestos control program rules and regulations enforced by the City of
		New York?

 

Any violation of the Asbestos Training regulations (10NYCRR73) of the New York State Department of Health?

A violation of any federal, state or local

a.apprenticeship requirement?

b.health regulation or statute?

c.environmental regulation or statute?

d.education regulation or statute?

e.law or regulation governing pensions including Employee Retirement Income Security Act (ERISA)?

		f. law or regulation governing payment of prevailing wages including the Davis-Bacon Act?
		g. law or regulation governing wages and hours including the Fair Labor Standards Act
		(FLSA)?
		A citation, administrative hearing or proceeding for violation of a federal Occupational Safety and
		Health Administrative (OSHA) standard?
		A federal or state suspension or debarment?
		A prevailing wage or supplement payment violation?
		A nonrenewal, suspension or revocation of any business or professional license?
		A failure to submit any quarterly payroll reports (Form NYS-45) or failure to pay any liabilities due to
		the New York State Unemployment Insurance Division.
		16. Disability Insurance

Disability Insurance is required in NYS if the applicant is a “covered employer,” i.e., if one or more of the applicant’s employees is employed in NYS for a least 30 days in any calendar year; the 30 days need not be consecutive. Covered employees must submit a copy of the Certificate of Disability Insurance (form DB-120.1) or Certificate of Disability Self Insurance (form # DB-155). Non-covered employers must submit a Certificate of Attestation of Exemption (CE-200) issued by the Worker Compensation Board.

Check one of the following:

I have disability insurance coverage. (Submit form DB-120.1 or DB-155.)

I am exempt from disability insurance coverage. (Submit form CE-200.)

This license is for a NYS government entity, or governmental subdivision within NYS, or a public school.

Acceptable forms of proof of

Workers’ Compensation Insurance

A)C-105.2: Certificate of Workers’ Compensation Insurance

B)CE-200: Certificate of Attestation of Exemption

C)U-26.3: State Insurance Fund’s version of C-105.2

D)SI-12: Certificate of Workers’ Compensation Self- Insurance

E)GSI-12: Certificate of Group Workers’ Compensation Self-Insurance

F)GSI-105.2: Certificate of Participation in Workers Compensation Group Self-Insurance

Check one of the following:

17.Worker’s Compensation Insurance

You must provide proof that you have Workers’ Compensation Insurance coverage or an exemption from such coverage (see list of acceptable forms in box at left). The New York State Department of Labor, License and Certification Unit, Building 12, Room 161A, State Campus, Albany, NY 12240 must be listed as a certificate holder. This certification may be obtained from the Workers’ Compensation Board District Office nearest you.

If you need more information about insurance contact the Workers’ Compensation Board, 180 Livingston Street, Brooklyn, NY 12248; (800) 877-1373, or www.wcb.state.ny.us.

___	I have worker compensation coverage and the compensation coverage is of the classification for the type of asbestos work
	to be conducted. (Submit form C-105.2, U-26.3, SI-12, GSI-12, or GSI-105.2.)

I currently have no worker compensation coverage because:

___	I have no employees and do not intend to hire employees. (Submit form CE-200.)
___	I have no employees at this time. (Submit CE-200.) When I do hire employees, I will obtain worker compensation coverage
	classified for the asbestos work conducted and submit an update with the proof of coverage.
___	This license is for a NYS government entity.

18.Certification of Child Support Obligations (not required for corporations or government entities)

Are you under an obligation to pay child support? If yes, complete items #1 - #4			Yes		No	

	1.	I am making payments in accordance with a plan agreed upon by the parties.	Yes		No	
	2.	I am four months or more behind in the payment of child support.	Yes		No	
3.		My child support obligation is the subject of a pending court proceeding	Yes		No	

4.		I am receiving public assistance or supplemental security income.	Yes		No	

Note: Any additional partner(s) in a partnership must complete form GO 1 Certificate of Child Support Obligations. To obtain the form go to www.labor.ny.gov, type GO 1 in the search box then click on GO 1 Appendix to a License.

19. Applicant Statement

This statement must be signed by the contractor, or a representative of the contractor who is authorized to sign on behalf of the company or organization named in this application.

Iunderstand that:

(a)This application is subject to verification and I agree to provide any additional documentation as required.

(b)Outside sources may be contacted to verify information contained in this application; and I give permission for the disclosure of any information which may be needed to process this license application.

(c)Failure to provide any of the requested or required information may result in rejection of this application.

(d)In order to complete this form, I must provide certain personal information. The authority to collect this information is found in the New York State Labor Law. This information will be maintained and used to process the application I am filing with the License and Certification Unit. Failure to provide this information may result in the inability to process my application. I also understand that by signing this I am granting permission to the Commissioner of Labor to provide access to my Unemployment Insurance (U.I.) benefit file.

(e)I swear or affirm as true the following:

(1)all persons employed by the applicant on any asbestos project whose duties involve the removal, encapsulation, enclosure, repair or disturbance of asbestos, or any handling of asbestos material that may result in the release of asbestos fiber or the supervision thereof, shall have valid asbestos handling certificates;

(2)the applicant will abide by all the rules and regulations promulgated pursuant to this article; and

(3)all the statements and information I have provided in this application are true to the best of my knowledge and belief.

False statements made herein are punishable as a class A misdemeanor pursuant to Section 210.45 of the penal law.

Signature of the Contractor or Duly Authorized Representative (No cosigns or stamps):

____________________________________________________________________________

Title: __________________________________________________________Date:__________

Prepare this application and submit:

a.An original to the New York State Department of Labor, License and Certification Unit, State Office Campus, Building 12, Room 161A, Albany, NY 12240. Retain a copy for your records.

b.A non-refundable fee of $500 for an original or $300 for a renewal license in the form of a check or money order, made payable to the Commissioner of Labor.

c.A photocopy of the Supervisor certificate issued to the contractor or to the supervisor designated as the contractor’s agent, listed in Box 13.

d.The required insurance certification.

Get Sh 430 PDF Form

Form Characteristics

Fact	Description
Type of License	The SH 430 form is for applying for either an original asbestos handling license or a renewal of an existing license, with respective fees of $500 and $300.
Governing Authority	This form is regulated under New York State labor laws, specifically those concerning asbestos handling and safety.
Location for Submission	Applications must be sent to the New York State Department of Labor, License and Certification Unit, located in Albany, New York.
Insurance Requirements	Applicants must provide proof of both Workers' Compensation insurance and Disability Insurance if employing individuals in New York State.
Affiliation Disclosure	The form requires disclosure of any affiliations with other organizations, particularly listing any owners or shareholders with significant stakes (5% or more).
Completion of Sections	Applicants are instructed to provide detailed answers for each section, including personal information about ownership and management structure of the company.
Affidavit Requirement	The applicant must affirm that the company’s activities won’t include actual asbestos abatement operations unless specifically checked in the provided sections.
Consequences of False Information	False statements made in this application can lead to serious penalties, classified as a class A misdemeanor in New York State.

Guidelines on Utilizing Sh 430

Completing the SH 430 form is an essential step for those seeking an asbestos handling license in New York State. Before you get started, make sure you have all the necessary information and documents to ensure a smooth application process. The following steps will guide you through filling out this form accurately and efficiently.

Indicate the type of license you are applying for—either Original or Renewal. Enter the license number only if it is a renewal.
Provide the name of your company or organization exactly as registered with the New York State Department of State.
Enter your Federal Employment Identification Number.
Choose the type of organization: Corporation, Partnership, Sole Proprietorship, Government, or Other.
If applicable, input your New York State Unemployment Insurance Employer Registration Number.
Fill in the incorporation details and the date when the company began operations under its current name.
Provide the street address, city, state, and zip code of the company.
Fill out the mailing address if it differs from the street address.
List the duly authorized representative including their name, social security number, job title, and business contact information.
If applicable, list all owners, partners, and shareholders owning five percent or more of the company.
Check if your company is an affiliate of any other organization and provide necessary details.
List all owners or shareholders owning ten percent or more of any affiliates, if applicable.
Select at least one type of asbestos work to be performed. If abatement is selected, provide the designated supervisor's details.
If abatement is not checked, affirm that your firm’s activities exclude actual asbestos abatement operations.
Answer the firm history questions with either “Yes” or “No” and detail any affirmative responses on a separate sheet.
Check to confirm whether you have disability insurance coverage or are exempt from it, providing relevant documentation.
Ensure proof of Workers’ Compensation Insurance coverage or provide an exemption, also supplying relevant documentation.
Complete the child support obligations section if applicable, only if you're not a corporation or government entity.
Sign the applicant statement to certify that all information is accurate and acknowledge that false statements may have legal consequences.
Prepare the application for submission, including the required fees and documents.

Once you have completed these steps, submit the original application to the appropriate address, along with any necessary fees and supporting documents. Retain a copy for your records. Careful attention to detail in filling out the SH 430 form can expedite the review process, helping you move forward with your asbestos handling activities.

What You Should Know About This Form

What is the SH 430 form used for?

The SH 430 form is an application for an asbestos handling license in New York State. Companies that plan to perform asbestos-related work must fill out this form to obtain the necessary permissions and ensure compliance with state regulations. Two types of licenses can be requested: an original license for new applicants and a renewal license for companies that already hold a license.

What does it cost to submit the SH 430 form?

For companies applying for an original license, the fee is $500. If you’re renewing an existing license, the fee reduces to $300. This fee must be submitted along with the completed application form in the form of a check or money order made out to the Commissioner of Labor.

Who needs to complete item 10 about affiliate organizations?

If your company is affiliated with another organization, you must complete item 10 on the SH 430 form. Affiliates are organizations that have a common ownership or control relationship with your company. Listing these connections is crucial for transparency and compliance with state regulations.

Is it necessary to provide Social Security numbers on the SH 430 form?

Yes, the form requires you to provide Social Security numbers for the duly authorized representative and others listed in sections related to ownership and management. This information helps the state verify the identities and backgrounds of individuals involved in managing the licensed activities.

What types of asbestos work can be checked in item 12?

Item 12 gives you options to specify the type of asbestos work your company will conduct. You can check one or more options, including abatement, management planning, project design, monitoring, inspection, or air monitoring. Make sure to choose the options that accurately reflect your planned activities to avoid compliance issues.

What happens if the application is disapproved?

If your application is disapproved, you will receive a notification detailing the reasons for the disapproval. Understanding these reasons can help you make the necessary adjustments to your application. Reapplying may be possible after addressing the issues that led to the disapproval.

How should I submit the completed SH 430 form?

You must submit the completed SH 430 form as follows: send an original copy to the New York State Department of Labor's License and Certification Unit at the specified address in Albany, NY. Keep a copy for your records, along with all required documents, such as proof of insurance and any supervisory certificates.

What if my company operates as a government entity?

If your organization is a government entity or a subdivision of NYS, you can skip certain sections of the SH 430 form related to business affiliations and child support obligations. However, you still need to meet other licensing and insurance requirements outlined in the form.

Common mistakes

Completing the SH 430 form can be a straightforward process if approached with care and attention to detail. However, many people make common mistakes that could lead to delays or even application disapproval. One prevalent error is failing to use the exact company name as registered with the New York State Department of State. Any variation, even a small one, can result in complications that may hinder the licensing process.

Another frequent mistake involves incorrectly entering the Federal Employment Identification Number (FEIN). This number is crucial for processing the application, and any discrepancies could cause significant delays. It is equally important to provide the correct New York State Unemployment Insurance Employer Registration Number. If you select the “Government” box, remember to skip the subsequent items specified in the form; otherwise, it may lead to wasted time and confusion.

Many applicants neglect to list all necessary owners, partners, and shareholders who own five percent or more of the company. This information is mandatory and should be accurately filled out, as not doing so can create further issues. In addition, the area for owners, partners, and shareholders who own ten percent or more of any affiliates is often overlooked. Complete this section diligently to ensure compliance with licensing requirements.

The types of asbestos work are another area prone to mistakes. When checking items related to asbestos work types, it’s essential to understand what category fits your operations best. Mis-marking this section may lead to relevant questions being unanswered, complicating the review process. If “Abatement” is marked, the form requires additional information in Question 13, which must not be ignored.

Failure to sign the application is a surprisingly common error. The applicant statement must include the signature of the contractor or an authorized representative. Omitting this essential step can result in the immediate rejection of the application. Equally, the signature needs to be original; no cosigns or stamps are acceptable.

Lastly, applicants frequently overlook the submission of required documents. This can include proof of disability insurance coverage or workers' compensation insurance as specified on the form. Missing documentation will halt the processing and could jeopardize your application timeline. Prior to submission, ensure that everything is in order by cross-checking the form against the requirements outlined in the application guidelines.

Documents used along the form

When applying for an Asbestos Handling License using the SH 430 form, you may encounter several other forms and documents that are essential for a smooth application process. Below is a list of these commonly used forms, along with a brief description of each. Having these documents ready can help ensure timely processing of your application.

DB-120.1 Certificate of Disability Insurance: A document that proves a business has disability insurance coverage for its employees, which is mandatory for certain employers in New York State.
DB-155 Certificate of Disability Self Insurance: Used by employers who wish to self-insure their disability insurance responsibilities. This certificate demonstrates compliance with state regulations.
CE-200 Certificate of Attestation of Exemption: This form indicates that a business is exempt from disability insurance coverage. It is necessary for employers without employees or those who do not hire in New York State.
C-105.2 Certificate of Workers’ Compensation Insurance: This is proof of workers’ compensation coverage, required for all businesses employing workers in New York State, ensuring they are insured against workplace injuries.
U-26.3 State Insurance Fund’s version of C-105.2: Similar to C-105.2, this form is another version of the certificate verifying that a business has workers' compensation insurance through the State Insurance Fund.
SI-12 Certificate of Workers’ Compensation Self-Insurance: Employers who choose to self-insure their workers' compensation insurance must utilize this certificate to demonstrate their compliance.
GSI-12 Certificate of Group Workers’ Compensation Self-Insurance: This document is used by employers who participate in a group self-insurance arrangement to cover workers' compensation liabilities.
GSI-105.2 Certificate of Participation in Workers’ Compensation Group Self-Insurance: A specific certificate providing proof of participation in a group self-insurance program for workers’ compensation.
GO 1 Certificate of Child Support Obligations: This form is required for certain applicants, particularly individuals, to certify their compliance with child support obligations as part of the license application process.
Form NYS-45 Quarterly Payroll Report: Employers are required to submit this form to report wages paid to employees and ensure compliance with unemployment insurance requirements in New York State.

These forms and documents play a crucial role in the application process for an Asbestos Handling License. Preparing them in advance can help streamline your experience and lead to a quicker review by the relevant authorities. Always ensure that you have the most up-to-date versions of these forms, as regulations may change over time.

Similar forms

Business License Application: This document is used by businesses to apply for a license to operate legally within a specific jurisdiction. Like the Sh 430 form, it collects essential information about the business, its owners, and the nature of its operations.
Workers' Compensation Insurance Application: Similar to the Sh 430 form, this application requires businesses to provide details about their employees and insurance coverage. Both documents aim to ensure compliance with state regulations for safety and labor.
Certificate of Authority Application: This document is filed by businesses seeking to operate as a foreign entity in another state. It parallels the Sh 430 by requiring business structure details, owner information, and official addresses.
Environmental License Application: Used by companies engaging in activities affecting the environment, this application gathers similar details regarding business ownership and previous compliance history. Both forms are vital for ensuring regulatory adherence.
Asbestos Abatement Notification Form: Like the Sh 430, this form is specifically focused on asbestos-related work. It requires detailed information about the contractors and their qualifications, ensuring that all personnel involved meet required safety standards.

Dos and Don'ts

When filling out the SH 430 form, it’s crucial to be careful and thorough. Here is a guide to help you navigate the process effectively.

Do read the form instructions carefully to ensure you understand what is required in each section.
Do provide accurate information. Double-check names, addresses, and identification numbers before submission.
Do ensure that all required signatures are affixed. Missing signatures can result in delays or denials.
Do retain a copy of the completed form for your records. This can be valuable for future reference.
Don’t leave any sections blank. If a question does not apply, clearly indicate that it does not apply.
Don’t use correction fluid or any other methods to alter the form. If a mistake is made, cross it out neatly and initial the change.

By adhering to these guidelines, you can enhance the chances of a smooth application process. Take the time to ensure everything is correct, and you will have peace of mind as you submit the form.

Misconceptions

Misconception 1: The SH 430 form is only for new applicants.

This form is actually used for both original license applications and renewals. Companies can renew their asbestos handling license by completing this form and paying the appropriate fee.
Misconception 2: There are no fees associated with the SH 430 form.

There are fees involved: a $500 fee for original applications and a $300 fee for renewals. It is crucial to include the correct fee when submitting the form.
Misconception 3: Completing the form guarantees license approval.

Submission of the SH 430 form does not ensure approval. Applications are reviewed, and disapproval can occur if requirements are not met.
Misconception 4: Only large companies need to fill out the SH 430 form.

Any company or individual intending to engage in asbestos handling, regardless of size, must submit this form. This includes sole proprietorships.
Misconception 5: The SH 430 form can be filled out by anyone in the organization.

Only a duly authorized representative, as specified in the form, is permitted to complete and sign the application. This ensures accountability.
Misconception 6: Background checks are not relevant for the SH 430 form.

Detailed personal and company history is crucial. Questions about past convictions and violations are included to assess eligibility and compliance.
Misconception 7: Insurance proof is optional when applying.

Proof of Workers’ Compensation and Disability Insurance coverage is required. Without it, the application may be rejected.

Key takeaways

Understanding the SH 430 form is crucial for obtaining an Asbestos Handling License in New York. Here are key points to keep in mind:

Complete all parts of the form accurately. Ensure the company name matches exactly as registered with the NYS Department of State.
Be prepared to pay a fee of $500 for an original application or $300 for a renewal. Include a check or money order made out to the Commissioner of Labor.
Include necessary proof of insurance. This includes Certificates of Disability Insurance and Workers' Compensation Insurance, depending on your status.
Provide information about all owners, partners, and significant shareholders. List members who hold five percent or more of the company's ownership.
Sign and date the application. This affirms that all information is accurate and that you understand the implications of the application process.

Taking these steps carefully will help facilitate the licensing process and ensure compliance with New York regulations.

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