A-TR1: Technical Report Statement of Responsibility

1 10/26/09 A-TR1: Technical Report Statement of Responsibility This form must be typewritten 1. Location Information Required for all applications. Premise no. Street Name TRU No. Close-out Type Check one: Full Partial 2. Applicant Information Required for all applications. Last Name First Name Middle Initial Business Name Business Telephone Business Address Business Fax City State Zip Mobile Telephone License Type choose one: Other.

2 License Number 3A. ID 3B. Identification of Requirement 3C. ACP-7 question 3D. Code Section Special Inspection Items 1 Photoluminescent Exit Path Marking ( Report required) 28F BC 2 Sprinkler Systems 28G BC 3 Standpipe Systems 28H BC

3 4 Sprayed Fire-Resistant Materials 29A BC 5 Smoke Control Systems 29B BC 6 Mechanical Systems 29B BC 7 Firestop, Draftstop, and Fireblock Systems 29B BC Progress Inspection Items 8 Fire-Resistance Rated Construction 29A BC 9 Public Assembly Emergency Lighting 28F Plumbing Inspection 10 Plumbing work 29D PC 107 Final Inspection 11 Final (Required for all A-TRU Jobs) Floor Entire Floor Section of Floor Inspection ID (See section 3A above) DOB Job# if filing conditional close-out form ACP20 Certificate of Complete Inspections/Tests Initial & Date 3.

4 Inspection Items 4. Locations of Abatement Required for all applications: 10/26/09 I have identified all of the inspections and tests required for compliance. Name (please print): Signature Date / Seal (apply seal, then sign and date over seal) Check all that apply below: For the special inspections indicated above in section 4, I certify that I am the principal/director of the inspection agency accepting Responsibility for having conducting the inspections and having performed all applicable work in accordance with the New York City Construction Codes and other designated rules and regulations.

5 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, 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 must 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 of the Administrative Code. For the progress inspections indicated above in section 4, I assume the Responsibility and I personally, or where permitted by the New York City Construction Codes, qualified personnel under my direct supervision, have performed the required inspections and tests.

6 I am aware of the additional sanctions imposed on false filings by of the Administrative Code. Final Inspection. I have made 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 confirm that the performance of progress inspections and other inspections has been documented before reporting the work as complete. Name (please print): Signature Date / Seal (apply seal, then sign and date over seal)

7 Inspector Information Last Name First Name Middle Initial Business Name Business Telephone Business Address Business Fax City State Zip Mobile Telephone License Type choose one: Other: License Number 5.

8 Design Applicant s Statement and Signatures responsible for plans. 6. Certification of Completion of Tests and Inspections Plumbing, Sprinkler, Standpipe Inspections and Tests. For the plumbing, sprinkler, or standpipe inspections indicated above in section 4, I certify that I have performed all applicable work in accordance with the New York City Construction Codes and other designated rules and regulations. I further certify that I have conducted all required inspections and tests, and that all work satisfied such test standards, including underground piping, roughing, and finish. For inspections and tests of gas piping, I certify that I meet the requirements of the NYC Construction Codes as they relate to the experience requirements set forth for gas tests.

9 I further certify that I have read the applicable sections of the New York City Construction Codes in connection with inspections and that I meet those qualifications for each and every inspection for which I take Responsibility . I agree that I must comply with all provisions of the New York City Construction Codes. I shall maintain all records of the inspections or tests for a minimum of six years after completion of the work. I realize falsification of any Statement is a misdemeanor punishable by a fine or imprisonment or both and may result in removal from participation in the self-certification program and/or disciplinary action. Name (please print).

10 Signature Date Seal (apply seal, then sign and date over seal Inspector Information Last Name First Name Middle Initial Business Name Business Telephone Business Address Business Fax City State Zip Mobile Telephone License Type.)