Nyc Form Tr2 – Fill Out and Use This PDF

Must be typewritten.

Sheet number 1

1Location Information Required for ALL applications.

House No(s)	Street Name
Borough	Block	Lot	BIN	CB No.
Work on Floor(s)				Apt/Condo No(s)

2	Licensed Concrete Testing Lab Information Required for ALL applications.
	Director Last Name		Director First Name				Director Middle Initial
	Business Name						Business Telephone
	Business Address						Business Fax
	City	State				Zip	Mobile Telephone
	E-Mail
	Director’s Lic. Number			P.E.		R.A.	Concrete Testing Lab Lic. Number
3	Licensed Concrete Testing Laboratory’s Identification of Responsibilities Required prior to Permit.
	Check all that apply below:

I certify that I am the director of the licensed concrete testing laboratory accepting responsibility for conducting the testing in accordance with BC 1905.6 and BC 1704.1. I further certify that I have read the applicable sections of the New York City Construction Codes in connection with the testing of concrete and licensed concrete testing laboratories as well as 1 RCNY §5-02 and 1 RCNY §101-07(c)(6), which specifies the qualifications and duties required of a licensed concrete testing laboratory and that this licensed testing laboratory meets those qualifications for the work for which I take responsibility. I agree that both I and the licensed concrete testing laboratory will comply with all provisions of the New York City Construction Codes as well as 1 RCNY §5-02 and 1 RCNY §101-07(c)(6). I am aware of the additional sanctions imposed on false filings by §28-211.1.2 of the Administrative Code.

Change of Applicant: I am a newly designated individual responsible for the testing specified herein and I hereby state that: None of the tests indicated herein have been performed to date by the previously designated individual.

Some of the tests indicated herein have been performed by the previously designated individual, as indicated in the attached report.

I am aware of the additional sanctions imposed on false filings by §28-211.1.2 of the Administrative Code.

Name (please print)

Signature

Date

P.E. / R.A. Seal (apply seal, then sign and date over seal)

10/09

TR2		Sheet number 2
4	Design Applicant’s Statement and Signature P.E./R.A. Required prior to Permit.

I certify that the licensed concrete testing laboratory specified in section 2 above and engaged by the owner to perform tests on the work at the location specified in section 1 above is acceptable. (BC 1704.1)

Name (please print)

Signature	Date

P.E. / R.A. Seal (apply seal, then sign and date over seal)

5Building Owner’s Statement and Signature Required prior to Permit.

I certify that I have employed the licensed concrete testing laboratory specified in section 2 above in accordance with BC 1704.1. 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 a fine or imprisonment, or both. I understand that if I am found after hearing to have knowingly or negligently made a false statement or to have knowingly or negligently falsified or allowed to be falsified any certificate, form, signed statement, application, report or certification of the correction of a violation required under the provisions of this code or of a rule of any agency, I may be barred from filing further applications or documents with the Department.

Name (print)	Title
Signature	Date

STOP HERE PRIOR TO PERMIT

10/09

TR2	Sheet number	of	sheets

6Test Report Required prior to Sign-off. Use supplemental pages as needed. Attach Original Lab Test Reports

Specified Concrete Str. (f’c):			PSI			Specified Test Age (days):
			Field Testing Results:
Test Report	Date of	Cylinder I.D.	Slump	Air Content	Temperature	Weight		Placement	Total	Breaking
Number	Placement							Location	Placement	Strength
			in	%	°F		lbs/ft3		yd3	PSI

Licensed Concrete Lab Director Name (please print)

Signature	Date

P.E. / R.A. Seal (apply seal, then sign and date over seal)

10/09

7 Licensed Concrete Testing Laboratory’s Certification of Completion Required prior to Sign-off.

I certify that I have completed the testing specified herein and that the results reported in section 6 of this form are true and accurate in accordance with §28-406.3.2.

I am aware of the additional sanctions imposed on false filings by §28-211.1.2 of the Administrative Code.

Withdrawal of Applicant: I am withdrawing responsibility for conducting the tests indicated herein and herewith submit the results or status of the work performed to date.

Name (please print)

Signature	Date

P.E. / R.A. Seal (apply seal, then sign and date over seal)

8 Design Applicant’s Statements and Signatures Required prior to Sign-off. P.E./R.A. responsible for plans, choose one and sign/seal.

I certify I have reviewed the test results reported by the licensed concrete testing lab in section 6 above and found them to be in compli- ance with the approved construction documents.

I certify I have reviewed the test results reported by the licensed concrete testing lab in section 6 above and found them to be in compli- ance with the approved construction documents except as noted in the attached report (BC 1905.6.3.3)

Note: design applicant’s signed and sealed report must be attached to this document

Name (please print)

Signature	Date

P.E. / R.A. Seal (apply seal, then sign and date over seal)

9Concrete Producer’s Statement and Signature Required prior to Sign-off. Must be filled out by Owner of Production Facility.

I certify that the test results reported in section 6 above were reported to me, and I further certify that the concrete delivered is in accordance with the design mix(es) specified on the TR3 submitted for the work specified in section 1 above.

	Name (print)		Title
	Signature	Date	NRMCA Expiration Date (BC 1905.8.2)
	Business Name		Business Telephone
	Business Address		Business Fax:
	City	State	Zip

10/09