Nyc Buildings Form Op128 – Fill Out and Use This PDF

Must be typewritten

Application must be double sided

Initial Filing

Correction Reference Num:_______________________

2Applicant Information Required for all applications.

	Last Name		First Name	Middle Initial
	Business Name			Business Telephone
	Business Address			Business Fax
	City	State	Zip	Mobile Telephone
	E-Mail			Filing Date (Mo/Yr)
3 Location Information Required for all applications.			Maximum of 20 activities per Ordinary Plumbing Work Report

*Work authorized to be performed pursuant to Administrative Code 28-105.4.4 (see instructions for details):

1)Removal of a domestic plumbing system not connected to a fire suppression system, or the removal of a portion of such system

2)Relocation of up to two plumbing fixtures within the same room to maximum of 10 feet from original location, except healthcare facilities

3a) Installation, replacement or repair of food waste grinder

3b) Installation, replacement or repair of internal (Secondary) backflow prevention (Test Letter Required - Department of Buildings) 3c) Replacement or repair of sump pump

4)Replacement of closet bend(s)

5a) For fewer than six families: replacement of gas fired boiler with a capacity of or under 350,000 BTU’s

5b) For fewer than six families: replacement of gas water heater with a capacity of or under 350,000 BTU’s

6)Repair or replacement of non-gas, non fire suppression piping not longer than 10 feet inside a building or connected piping previously repaired or replaced under the provisions of Administrative Code 28-105.4.4

7)Repair or replacement of non-fire suppression branch piping after the riser shut-off valve, including the replacement of fixtures, limited to two bathrooms and one kitchen per building per each monthly reporting period

Please Note that Primary Backflow Prevention must be filed as an Limited Alteration Application

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OP128

PAGE 2

Please check if the following apply:

If I am working on the replacement of a gas fired boiler or a gas water heater with a capacity of or under 350,000 BTU’s, I certify the gas cock has not been moved, the chimney is in good operational condition, and no gas piping has been installed/replaced with the installation of this

heating equipment.	Print Name of Licensed Master	Seal
I certify the statements herein are correct and comply with the NYC	Plumber (LMP)
Building Code. I meet the requirements of the NYC Building Code as
they relate to the experience requirements set forth in Building Code
Section 28-105.4.4. I understand falsification of any statement is a
misdemeanor under Sections 28-201.2.1.2, 28-203.1.1, and 28-211.1 of
the Administrative Code punishable by a fine or imprisonment or both and	Signature
may result in the removal from participation in the self-certification
program and/or disciplinary action by the Plumbing and Fire Suppression	Date
Piping Contractor License Board.

Purpose of form:

This monthly report is to be used by Licensed Master Plumbers filing work that the code details as Ordinary Plumbing Work as per section 28-105.4.4. This work doesn’t require a permit. The report must specify all work underway or done by the plumber during the previous month. Forms must be submitted to DOB by the 15th of the month after the month for which the work is being reported. Those who fail to file and late filers will be subject to violations and/or disciplinary action. License and insurance must be active at time of filing.

Report Submittal:

All reports must have a sticker affixed with the applicant’s license number. License number stickers are available at the Plumbing Inspections office at 280 Broadway, 4th Floor, in Manhattan.

The Department’s LAA unit must receive all reports, with a fee of $100 per report, by the 15th of the month for the previous month’s ordinary plumbing work, and report’s must include a self-addressed, stamped envelope. Reports may be mailed or delivered to: Department of Buildings ARA/Permit Renewals, 280 Broadway - 5th Floor, New York, NY 10007.

Filing of this report does not relieve the applicant of obligation to comply with the applicable requirements of the Department of Environmental Protection with regards to asbestos abatement

1 Applicant of Record Information

•Please provide the last name, first name, middle initial, business name, business address, business telephone number, fax number, mobile number, e-mail address, and filling month (specify month/year).

2 Location Information

•Please provide the borough number, block, lot, BIN #, address (house #, street, floor, apt #), residential or commercial (R or C), date, completion status (Y or N). Additionally, list # of fixtures, kitchen or bathroom (K or B), installation, repair, replacement, relocation and the appropriate work # where applicable for each ordinary plumbing repair

•Please refer to the Building Code section §28-105.4.4 excerpt below for what is required to be reported as Ordinary Plumbing Work.

•The items listed below are followed by parenthetical references corresponding to the listing above of ordinary plumbing work authorized to be performed and detailed on this form. Use those references when completing the last column on page 1.

1.The removal of a domestic plumbing system not connected to a fire suppression system, or the removal of a portion of such system. (for 1 on the report)

2.The relocation of up to two plumbing fixtures within the same room to a maximum of 10 feet (3048 mm) distant from the original location, except in health care facilities. (for 2 on the report)

3.The installation, replacement or repair of a food waste grinder (food waste disposal) or back flow preventer and the replacement or repair of a sump pump. (for 3a, 3b, 3c on the report)

4.The replacement of closet bends. (for 4 on the report)

5.In buildings in occupancy group R2 occupied by fewer than six families or in buildings in occupancy group R3, the replacement of a gas water heater or a gas fired boiler with a capacity of 350,000 BTU or less where the existing appliance gas cock is not moved, provided the chimney has been inspected as/per NYC Fuel Gas Code section 503.5.6. (for 5a, 5b on the report)

6.The repair or replacement of any non-gas, non-fire suppression piping not longer than 10 feet (3048 mm) inside a building, or connected piping previously repaired or replaced under this provision. (for 6 on the report)

7.The repair or replacement of non-fire suppression branch piping after the riser shutoff valve, including the replacement of fixtures, limited to two bathrooms and one kitchen per building per monthly reporting period. (for 7 on the report)

3 Applicant Statement and Signature

•Please certify that the gas cock has not been moved and the chimney is in good operational condition if filing replacement of a gas fired boiler or a gas water heater

•Review all statements in this section in detail before signing.

•Print name, date, sign and seal.

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