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Get NY PW4 2015-2024

PW4 Application for Certificate of Compliance for Equipment Orient and affix BIS job number label here Must be typewritten. 1 Filing Status Job Number 2 Type of Equipment Required for all applications. Name Inspector s Signature P. E. / R.A. Seal apply seal then sign and date over Date Signed Off seal INTERNAL USE ONLY Examined and Recommended for Approval Yes Examiner No Approved Borough Commissioner PW4 2/15. Heating System Not including boilers Ventilation System Air Conditioning System Refrigeration 3 Location Information Required for all applications. House No* Street Name Borough Apt/Condo No s Block Lot BIN CB No* Work on Floor 4 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 R*A. Other License Number E-Mail P. E* 5 Equipment Specifications Instructions for section complete all. Item Manufacturer/Trade Name Floor No* of Items Certification Number for Listing Capacity BTUs/CFM 6 Statement and Signatures Required for all applications. The owner certifies that he authorizes the applicant to perform the proposed work in accordance with plans and specifications approved under said application* Falsification of any statement is a misdemeanor and is punishable by a fine or imprisonment or both. It is unlawful to give to a city employee or for a city employee to accept any benefit monetary or otherwise either as a gratuity for properly performing the job or in exchange for special consideration* Violation is punishable by imprisonment or both. Name please print Signature Date Owner Name Title I hereby certify that the work indicated above has been done in a manner required by the Rules and Regulations of the Department of Buildings except where reported adversely. Heating System Not including boilers Ventilation System Air Conditioning System Refrigeration 3 Location Information Required for all applications. House No* Street Name Borough Apt/Condo No s Block Lot BIN CB No* Work on Floor 4 Applicant Information Required for all applications. House No* Street Name Borough Apt/Condo No s Block Lot BIN CB No* Work on Floor 4 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 R*A. Last Name First Name Middle Initial Business Name Business Telephone Business Address Business Fax City State Zip Mobile Telephone R*A. Other License Number E-Mail P. E* 5 Equipment Specifications Instructions for section complete all. Other License Number E-Mail P. E* 5 Equipment Specifications Instructions for section complete all. Item Manufacturer/Trade Name Floor No* of Items Certification Number for Listing Capacity BTUs/CFM 6 Statement and Signatures Required for all applications. Item Manufacturer/Trade Name Floor No* of Items Certification Number for Listing Capacity BTUs/CFM 6 Statement and Signatures Required for all applications. The owner certifies that he authorizes the applicant to perform the proposed work in accordance with plans and specifications approved under said application* Falsification of any statement is a misdemeanor and is punishable by a fine or imprisonment or both. .

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