Fillable Fire Alarm System - Inspection & Testing Certification Form printable pdf download

PAUL HOULIHAN

I n c o r p o r a t e d V i l l a g e O f W e s t h a m p t o n B e a c h

Building & Zoning Administrator

D E P A R T M E N T O F B U I L D I N G A N D Z O N I N G

1 6 5 M i l l R o a d

BRIDGET NAPOLI

W e s t h a mp t o n B e a c h , N e w Y o r k 1 1 9 7 8

Ordinance Enforcement Officer

( 6 3 1 ) 2 8 8 - 3 4 7 8 – F a x ( 6 3 1 ) 2 8 8 - 4 3 3 2

WILLIAM HART

Fire Marshal

Tax Map #_____-_____-_____

Official Use Only

Approved [

] Disapproved [

]

FIRE ALARM SYSTEM

FM __________Date __________

Inspection & Testing Certification Form

CAUTION: NOTIFY ALL OCCUPANTS AND ANY AGENCIES WHO MIGHT RESPOND BEFORE

TESTING SYSTEM. FAILURE TO DO SO MAY RESULT IN LEGAL ACTION AGAINST THE

INSPECTOR!

PLEASE PRINT OR TYPE ALL INFORMATION

Name of Premises:_____________________________________________________________________________

Address of Premises:___________________________________________________________________________

Fire District as Listed on Central Station Records:___________________________________________________

Name of Occupant/Agent Present:________________________________________________________________

Type of System: ____________________________

System Carbon Monoxide Detectors Tested?

Y / N

(Manual, Automatic, Voice Evacuation, etc.)

Name of Central Station:_______________________________ Central Station Phone Number:__________________

List deficiencies noted:___________________________________________________________________________

______________________________________________________________________________________________

Were all deficiencies noted above corrected?______ If not, why:_________________________________________

Name of Inspecting Firm:__________________________________________________________________________

Address of Inspecting Firm:________________________________________________________________________

NYS Alarm License #:____________________________________Expiration Date___________________________

Phone Number of Inspecting Firm:__________________________ Date of Inspection:_________________________

CERTIFICATION:

I, an employee of the Inspecting Firm listed above, do hereby certify that the fire alarm system

described above was inspected in accordance with the applicable portions of NFPA 72 (Current Version), particularly

Chapter 7 as well as Table 7-2.2 and Table 7-3.1 of NFPA 72. This Certification does not imply that items requiring daily,

weekly, monthly or quarterly inspection or testing were performed at the specified intervals, but does imply that all such

items were inspected or tested and appeared to function as noted in this certification at the time of the inspection. I certify

that this inspection has been properly conducted and all of the above statements are true and correct to the best of my

knowledge.

________________________________

____________________________________

________________

Print Name of Inspector

Signature of Inspector

Date

ANY FALSE STATEMENT MADE HEREIN IS PUNISHABLE AS A MISDEMEANOR PURSUANT TO SECTION

210.45 OF THE NEW YORK STATE PENAL LAW.

(This form does not need to be notarized.)

F:\Building permits and review\Building Dept. Forms\2007\Fire Alarm Test 4.27.07.doc

Fire Alarm System - Inspection & Testing Certification Form

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