Boiler Renewal Form – Fill Out and Use This PDF

Section

1.Premises Address (always required)

2.Building Occupancy (always required)

3.Owner

(always required)

4.DOB Inspection Report (If DOB annual boiler inspection report is being filed, this section to be completed by the individual performing the inspection.)

Instructions

•Provide the borough, block, lot, and Building Identification Number (BIN optional) of the building where the boiler(s) is/are located.

•Provide the house number, street name and zip code of the building where the boiler(s) is/are located.

•If applicable, list the special place name associated with the building where the boiler(s) is/are located, e.g. 2nd Floor Rear, JFK Airport, Terminal 8, sub- basement, etc.

•Check (X) “Multiple Dwelling”, “Commercial”, “Mixed Use” or “Other” to indicate the occupancy classification for the building where the boiler(s) is/are located. If “Other”, please indicate in space provided.

•Provide total number of residential units in the building where the boiler(s) is/are located.

•If ownership information is different than most recent previous filing, please check (X) box.

•Provide name and business telephone number for boiler/building owner.

•Provide mailing address, city, state, zip code and e-mail address (optional) for boiler/building owner.

•Provide a contact person (if different than owner), relationship to the owner, and his/her business telephone number.

•Provide contact person’s mailing address, city, state, zip code and e-mail address (optional).

•Indicate the date that a licensed NYC boiler inspector performed the inspection of the boiler(s) at the building indicated in section 1. Check “Internal” or “External” to indicate the type of inspection performed. Internal and external inspections can be filed at the same time by selecting both boxes. Note: Only insurance company representatives or high pressure boiler operators may conduct internal inspections.

•If the property is fee exempt, check “Real Estate $0.00 tax bill” or “Verification Letter from Department of Finance” to indicate type of proof submitted to verify fee exempt status.

•For each boiler inspected, indicate DOB boiler number, DEP installation number (if necessary, repeat DEP installation number for each corresponding DOB boiler number), DEP expiration date, boiler make, boiler model, “Hi” or “Lo” pressure, pressure per square inch (PSI), the floor the inspected boiler is located on, and any violating conditions discovered during the inspection.

•Indicate the number of boilers inspected in the space provided. Multiply each boiler inspected by the $30 DOB filing fee to calculate the total DOB fee required for this submission. Note: This number must be entered in section 8 on reverse side of the form.

Section

5.Boiler Insurance Company

(to be completed only if insurance company performs DOB inspection)

6.Authorized NYC Boiler Inspector

(to be completed by licensed NYC boiler inspector if DOB annual inspection report is filed)

Instructions

•Indicate name of insurance company, contact person at insurance company and business telephone number of contact person at insurance company.

•Indicate mailing address, city, state and zip code of contact person at insurance company.

•Indicate name of policyholder, certificate/policy number and expiration date of policy.

•Indicate address, city, state and zip code of policyholder.

•Affix seal of licensed NYC boiler inspector who performed inspection in space provided at left.

•Indicate name and license number of authorized NYC boiler inspector who performed inspection.

•Check (X) “Insurance Company”, “High Pressure Boiler Operator”, “Master Plumber”, or “Oil Burner Equipment Installer” to indicate type of inspector that performed the inspection. Note: These are the only types of inspectors authorized to perform DOB annual boiler inspections. Licensed Master Plumbers and Oil Burner Equipment Installers are authorized to perform low pressure boiler inspections only.

7.Department of Environmental Protection

(to be completed by owner/agent only in DEP expiration year)

•This section is only to be completed by the owner/representative/agent. Insurance companies do not complete this section.

•Check “Renew Registration” or “Renew Certificate to Operate” to indicate the type of filing.

•Select “Renew Certificate to Operate” if any one of the following apply:

a)Boiler device is above 2.8 million BTU

b)Boiler device uses #4 oil and is above 1 million BTU

c)Boiler device uses #6 oil

•Select “Renew Registration” for all other boiler devices.

•For each renewal request, indicate the Installation #, Expiration Date, # of Identical Units, and the fee amount for each installation. Obtain the required fee amount by reviewing the DEP expiration notice (received by mail) or on the DEP website at www.nyc.gov/dep. Indicate the sum of all required fees in the space provided next to “DEP Total Fee”.

•If the property is fee exempt, check “Real Estate $0.00 tax bill” or “Verification Letter from Department of Finance” to indicate type of proof submitted to verify fee exempt status.

•Provide the name and telephone number for the contact person (if different than listed in section 3) to schedule inspection, provide access and operate equipment to demonstrate compliance.

•Provide the address, apartment number, city, state and zip code of the individual listed as owner/superintendent/contractor/agent.

•Provide fax number and e-mail address (optional) of the individual listed as owner/superintendent/contractor/agent.

•Provide signature of the owner or representative with title and date.

•Affix the seal and signature of the Professional Engineer or Registered Architect as per Section 24-123(d) of the Administrative Code of the City of New York (required only for “Renewal of Certificate to Operate”).