Fillable Technical Report (Tr6) Form printable pdf download

Technical Report (TR6)

Periodic Inspection of Exterior Walls and Appurtenances

Sub-Cycle 8A – February 21, 2015 — February 21, 2017

Sub-Cycle 8B – February 21, 2016 — February 21, 2018

Place stamp here

Sub-Cycle 8C – February 21, 2017 — February 21, 2019

Must be typewritten.

For all reports, submit a digital copy of report in a DVD or CD format , a BIS Façade printout, a completed TR-6 and the Batch Intake

Control #: __________________

form (FBI1). The digital copy must be indexed with a Control Number and BIN. E.g. Control # -- BIN

1 Filing Information

(Indicate if combined cycles)

Initial Filing

Resubmission

Amended Filing

Subsequent Filing

Report cycle: _______________

Report cycle: ___________

Initial filing date: _____________

Last cycle filing date: _______________

Initial unsafe filing date: ____________

2 Location Information

House No(s)

Street Name

Zip

CB No

BIN

Borough

AKA

Block

Lot

3 Inspection Report Status Information

Current Cycle: Last Inspection Date ___________

SWARMP Recommended Date ___________

Prior Filing Cycle _________

Safe

Safe with repair and maintenance program (SWARMP)

Unsafe

Safe

SWARMP

Unsafe

4 Building Characteristics

Landmark Building:

Yes

Landmark District:

Yes

Wall(s) Subject to Inspection

Number of stories:

Exterior wall type:

# Balconies:

All

Partial

5 Qualified Exterior Wall Inspector (QEWI) Information

Last Name

First Name

Bus. Name

Bus. Address

Bus. Tel.

City

State

Zip

Bus. Fax

NYS Lic. #

P.E.

R.A.

Mobile Phone

E-Mail

6 Owner of Record Information

(Not a Representative or Business Manager or Agent)

Last Name

First Name

Bus. Name

Bus. Address

Bus. Tel.

City

State

Zip

Bus. Fax

E-Mail

Mobile Phone

7 Statements and Signatures

Owner / Owner Representative

Qualified Exterior Wall Inspector (QEWI)

(A) I hereby state that I am the owner/owner’s representative of the premises referenced

Name (please print)

in the attached report. Furthermore, I have received and read a copy of the attached

report and I am aware of the required repairs and/or maintenance, if any and the

Signature

Date

recommended time frame for same.

(B) I certify that all items noted as SWARMP conditions in the previous cycle’s report

have been corrected/repaired; or this report must be rated as Unsafe as per

I hereby state that the Owner / Owner’s Representative

Administrative Code section §28-302.1, if applicable.

has authorized me to submit this report. Furthermore, I

hereby state that all statements are correct and complete

to the best of my knowledge. A copy of this report has

Name _____________________________

Signature _______________________

been given to the owner.

Relationship to owner ________________

Phone _________________________

P.E. / R.A. Seal (apply NYS seal, then sign and date)

Email ______________________________________________

Date ___________

§28-211.1 False statements in certificates, forms, written statements, applications, reports or certificates of correction. It shall be unlawful for any person to make a material

false statement in any certificate, professional certification, form signed statement, application, report or certification of the correction of a violation required under the provi-

sions of this code or any rule of any agency promulgated there under that such person knew or should have known to be false.

TR6 Rev: 2/15