Get Fire Alarm Certification Form

PAUL HOULIHAN Incorporated Village Of Westhampton Beach Building Zoning Administrator DEPARTMENT OF BUILDING AND ZONING 165 Mill Road 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 8 631 288-3478 Fax 631 288-6275 BRIDGET NAPOLI Ordinance Enforcement Officer WILLIAM HART Fire Marshal Tax Map -- Official Use Only FIRE ALARM SYSTEM Approved Disapproved 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 Is Occupancy Type same as previous test 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* FORM WITH AN ORIGINAL SIGNATURE IS REQUIRED DO NOT SEND BY FAX This form does not need to be notarized*. 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 Is Occupancy Type same as previous test 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.