Form Op-98 - Notice/results - Self-Certification Of Plumbing, Sprinkler, Standpipe Inspections(S) & Test(S)

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S c a n

S t i c k e r

h e r e

OP-98

Notice/Results—Self-Certification of Plumbing,

Sprinkler, Standpipe Inspection(s) & Test(s)

A copy of this completed notice must be retained for re-submission with results.

1 Permit No.

Document No.

LAA

Permit Type (check one only):

Borough

Block

Lot

House No

Street Name

2 Permit Applicant

E-Mail:

Business Phone (

)

Fax No. (

)

First Name

Business Name

Last Name

M.I.

Address

City

LMP

LFSC

State

ZIP

License No.

3 Inspection Data

Inspection/test scheduled for:

___/___/___

Time:

8:00am

8:30

9:00

9:30

10:00

10:30

11:00

11:30

12:30pm

(mmddyy)

Apts and Floors:

1:00pm

2:00

Meeting Location:

1:30

2:30

3:00

4 Notice/Result

(Select one: PL, SP, SD only)

Systems:

Systems

Plumbing (PL)

Sprinkler (SP)

Standpipe (SD)

Underground

Finish

Underground

Roughing

Finish

Underground

Roughing

Finish

Roughing

Inspections

Notice

Results

Notice

Results

Notice

Results

Notice

Results

Notice

Results

Notice

Results

Notice

Results

Notice

Results

Notice

Results

Fail

Sprinkler - SP

Sprinkler - PL

Fire Standpipe - SD

Water/Sanitary - PL

Storm - PL

Gas - PL

Alarm Sys 64/09

Medical Gas - PL

Tests

Notice

Results

Notice

Results

Notice

Results

Fail

Hydrostatic - SP

Hydrostatic - PL

Hydrostatic - SD

Water - Sanitary

Dry Pipe Valve

Fire Pump

Booster Pump

Pressure - Water

Water Storm

Gas Tested at psi

50 psi

3 psi

Gas

100 psi

90 psi

Hydrostatic 63/09

75 Ft

100 Ft

Medical Gas

Additional Information/Comments:

Submitted with minor variations, described here:

Legalization

Gas to Gas Appliance Direct Replacement

Remove/Cap

Detention

Drywell/Retention

5 Gas Meters/Risers Data

Gas requested for listed meters and risers

(Check all applicable to this inspection. Include gas usages for each listed meter(s)/riser(s))

No. of Risers:

Location(s) (Floor/Apt.):

No. of Meters:

Location(s) (Floor/Apt.):

Welded Gas Piping

Boiler Pilot for oil burner

Dryer

Gas usage:

Heat

Water Heater

Cooking

Tankless Coil

HVAC

Fire Place

Other (describe):

6 Certifying Applicant

E-Mail:

Business Phone (

)

Fax No. (

)

First Name

M.I.

Business Name

Last Name

City

State

P.E.

R.A.

ZIP

LMP

LFSC

License No.

Address

7 Applicant Statements and Signatures

All Comments resolved, review for sign-off

All required back-up documents attached

I certify the statements herein are correct and comply with the NYC Building code. I meet the requirements of the NYC Building code as they relate to the experience requirements set forth for gas tests. I realize

falsification of any statement is a misdemeanor under §28-211.1 of the Administrative code punishable by a fine or imprisonment or both and may result in removal from participation in the self-certification program and/or disciplinary

action by the Licensed Master Plumber or Licensed Fire Suppression Piping Contractor License Board.

SEAL

Print Name of Permit Applicant or Alternative

SEAL

Print Name of Certifying Applicant

licensee from same firm (LMP/LFSC)

Signature

Date

FOR DOB USE ONL

FOR DOB USE ONLY Y Y Y Y

FOR DOB USE ONL

Reviewed by:_____________, Date:__________, Entered by:_____________, R.S.O. by:_____________, S/O by:______________