Op49: Self-Certification Of Removed, Disconnected, Or Non-Existing Boiler

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OP49: Self-Certification of Removed, Disconnected, or Non-Existing Boiler

Note: This form must be filed within thirty (30) days following boiler disconnection or removal. Only one form per boiler.

1 Location Information

Borough

Block

Lot

BIN

Total # Res. Units

House No(s)

Street Name

AKA

Total # Commercial Space

Occupancy

Multiple Dwelling

Commercial

Mixed Use

Other (describe)

2 Owner/Representative Information

Last Name

First Name

Daytime Telephone

Address

Mobile Telephone

City

State

Zip

E-Mail

Contact Person

Daytime Telephone

E-Mail

Mobile Telephone

3 Authorized Inspector Information

Last Name

First Name

License Number

Business Name

Business Telephone

Business Address

Mobile Telephone

City

State

Zip

E-Mail

License Type

Oil Burner Equipment Installer (O)

High Pressure Boiler Operator (B)

RA (Registered/Licensed Architect)

Master Plumber (P)

Authorized Insurance Company

PE (Licensed Professional Engineer)

4 Boiler Disposition Information

*Owner must provide adequate documentation if reporting a disconnect/removal date prior to the Inspection Date.

4A Boiler Number:

Serial Number:

Inspection Date:

Disconnect 4C, 4E

Removal 4C, 4E

Post Disconnect/Removal Inspection 4C, 4D, 4E, 5

Non-Existing 4E

The following conditions for proper boiler disposition were performed, or inspected, and are in accordance with all NYC Administrative Code

and other applicable laws and rules: [1] oil burner is removed from boiler (if gas burner, gas line is capped), [2] water supply to boiler is cutoff,

[3] electric supply to boiler is disconnected, [4] steam or hydronic header and return is cut above boiler and physically disconnected, and [5]

flue pipe is removed from chimney base.

4D Provide actual date of disconnect/removal for this boiler unit*:

4E Are there any active boilers remaining at this location?

Yes 4F

No 4G

4F Provide information for each active boiler at this location.

4G Explain how the building is being heated and provide Job/Permit number(s)

Boiler Number

Serial Number

and/or Equipment Use number for the alternate device(s).

(←check here if) active devices heat individual residential

units and are each 100,000 BTU’s or less.

5 Owner’s Statements and Signatures

Falsification of any statement is a misdemeanor and punishable by a fine, 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 imprisonment or fine 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)

Signature

Date

6 Authorized Inspector’s Statements and Signatures

Falsification of any statement is a misdemeanor and punishable by a fine, 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 imprisonment or fine 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)

Signature

Date

Licensee Seal (apply seal, then sign and date over seal)

Only one form per boiler.

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