Tr1: Technical Report Statement Of Responsibility Page 3
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Required when inspection applicant identifies responsibilities.
6 Owner’s Statement and Signature for Progress/Special Inspector
I have reviewed the information provided herein and, to the best of my knowledge and belief, attest to its accuracy. I approve the identification of
the responsible inspector. Falsification of any statement is a misdemeanor and is punishable by a fine or imprisonment, or both. It is unlawful to
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. Violation is punishable by a fine or imprisonment, or both. I understand that if I am found after hearing
to have knowingly or negligently made a false statement or to have knowingly or negligently falsified or allowed to be falsified any certificate,
form, signed statement, application, report or certification of the correction of a violation required under the provisions of this code or of a rule of
any agency, I may be barred from filing further applications or documents with the Department.
Name (print)
Title
Signature
Date
7 Inspection Applicant’s Identification of Responsibilities
Check all that apply below:
For the special inspections indicated above in section 3, I certify that I am the principal/director of the special inspection agency accepting
responsibility for conducting the inspections. I further certify that I have read the applicable sections of the New York City Construction Codes in
connection with special inspections as well as 1 RCNY 101-06 Rule, which specifies the qualifications required for each inspection and that this
agency meets those qualifications for each and every special inspection for which I/we take responsibility. I agree that both I and the agency will
comply with all provisions of the New York City Construction Codes and the Rule. I am aware of the additional sanctions imposed on false filings
by §28-211.1.2 of the Administrative Code.
For the progress inspections indicated above in section 4, except energy code inspections on the TR8 form, and/or concrete test items
indicated in section 3,
I assume the responsibility and I personally, or where permitted by the New York City Construction Codes, qualified
personnel under my direct supervision, will perform the required inspections and tests on such forms and in such matter as the Department
requires or requests.
I am aware of the additional sanctions imposed on false filings by §28-211.1.2 of the Administrative Code.
Final Inspection:
I will make final inspection of the construction work, including those inspections during its progress necessary to my certification upon final
inspection that all work substantially conforms to approved construction documents and applicable laws and rules. I will confirm that the
performance of progress inspections and other inspections has been documented before I report the work complete. As prescribed by 1 RCNY
101-10, I will perform the final inspection within 1 year from the expiration of the last valid permit of the work.
Upon completion of the work and within 30 days of my final inspection, I will file a certification attesting to the fact that all work was performed and
completed in accordance with the approved construction documents, laws and rules, except as reported otherwise.
I understand that my failure to file a certification of completion or to notify the Department of my withdrawal of responsibilities within
one year from expiration of the last valid permit may result in the loss of my privileges to file under Directives 2 and 14 of 1975 or
issuance of a violation, or both. I am aware of the additional sanctions imposed on false filings by §28-211.1.2 of the Administrative
Code.
Change of Applicant: I am a newly designated individual responsible for the items specified herein and I hereby state that:
None of the inspections/tests indicated herein have been performed to date by the previously designated individual.
Some of the inspections/tests indicated herein have been performed by the previously
designated individual, as indicated in the attached report.
I am aware of the additional sanctions imposed on false filings by §28-211.1.2 of the Administrative Code.
Name (please print)
Date
Signature
P.E. / R.A. Seal (apply seal, then sign and date over seal)
8 Inspection Applicant’s Certification of Partial Completion
9 Inspection Applicant’s Certification of Full Completion
I have completed the items specified herein and certify that the all
All work performed substantially conforms to approved construc-
work performed substantially conforms to approved construction
tion documents and has been performed in accordance with
documents and has been performed in accordance with applica-
applicable provisions of the New York City Construction Codes
ble provisions of the New York City Construction Codes and
and other designated rules and regulations.
other designated rules and regulations, except as indicated in the
I am aware of the additional sanctions imposed on false filings
attached report.
by §28-211.1.2 of the Administrative Code.
I am withdrawing responsibility for the
Withdrawal of Applicant:
items of special/progress
inspections and/or tests indicated here-
Name (please print)
in and herewith submit the results or status of the work performed
Date
Signature
to date.
P.E. / R.A. Seal (apply seal, then sign and date over seal)
I am aware of the additional sanctions imposed on false filings by §28-
211.1.2 of the Administrative Code.
Name (please print)
Date
Signature
P.E. / R.A. Seal (apply seal, then sign and date over seal)
TR1
August 2016
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