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House #
 
Street Name
 
  Borough
 
 
 
Notice for Plumbing Self-Certification

This form must be received and accepted by this Department at least two (2) working days prior to the the date of inspection/self-certification.

     

Date:                       * = Required Field


1 Job Data
 

 
Borough*
 
Block
 
Lot
 
House No.*
 
Street Name*
 
Permit No*
 
Job No. (if different from permit No.)
 
Document No.*
 
Permit Type (Check One Only)*
PL   SP SD LAA (formerly ARA)
 

2 Permit Applicant data
(Details of applicant who obtained the permit)

Last Name*
First Name*
M.I.
Business Name*
 
Fax No.*
-  
Bus. No.*
-  
Address*
 
City*
 
State*
 
Zip*
-  
License Number *
  LMP    LFSC
Applicant E-Mail
 

3 Inspection data

Inspection/test scheduled for*
 
Time
8:00am  8:30am  9:00am  9:30am  10:00am  10:30am  11:00am
11:30am 12:30pm 1:00pm  1:30pm  2:00pm   2:30pm    3:00pm
 
Floors/Apts*
 
Meeting Place*
 

4 Notice ( Select One Worktype ONLY: PL, SP, SD )

Plumbing (PL)

System Inspections:
Underground
Roughing
Finish

Sprinkler - PL

 

 

Water/Sanitary - PL

 

Storm - PL

 

Gas - PL

 

Type of Test(s):
 

Water Storm

 

Gas

 
Sprinkler (SP)
System Inspections:
Underground
Roughing
Finish

Sprinkler - SP

 

 

Type of Test(s):

Dry Pipe Valve

 
Standpipe (SD)
System Inspections:
Underground
Roughing
Finish

Fire Standpipe - SD

 

 

Alarm System 64/09

 

 

Type of Test(s):

Fire Pump

            

 

Hydrostatic 63/09

 

 
 Additional Information/Comments:

Legalization

 

 Detention Tank  Drywell/Retention

5 Gas Meters/Risers Data
(check all applicable to this inspection. Include gas usage for each listed
meter(s)/riser(s))

No. of Meters
 
Locations(s) (Floor/Apt. for this inspection)
 
No. of Risers
 
Locations(s) (Floor/Apt. for this inspection)
 
Gas Usage:
Heat
Boiler Pilot for oil burner
Water Heater 
Dryer
Other (describe):
Cooking
Tankless Coil
HVAC
Fire Place

   
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