Tr 1 Form – Fill Out and Use This PDF

TR1: Technical Report
Statement of Responsibility		Orient and affix BIS
			
		job number label here
This form must be typewritten

1Location Information Required for all applications.

House No(s)	Street Name

Work on Floor(s)

2Applicant Information Required for all applications.

Choose all that apply:	Design Applicant 3A, 4A, 5					Special Inspections Applicant 3B-D, 6-9		Progress Inspections Applicant 4B-D, 6-9
Last Name							First Name	Middle Initial
Business Name								Business Telephone
Business Address								Business Fax
City		State					Zip	Mobile Telephone
License Type	choose one:	P.E.			R.A.		Other:	License Number
								Special Inspection
								Agency Number

3Special Inspection Categories Required for all applications, continued on page 2; █ indicates report required.

3A ← Identification of Requirement

3B Identification of

3C Certificate of Complete

3D Withdraw

Responsibilities

Inspections / Tests

Responsibilities

Y N Special Inspections

Code/Section

Initial & Date

Initial & Date

Initial & Date

Structural Steel – Welding

BC 1704.3.1

Structural Steel – Details

BC 1704.3.2

Structural Steel – High Strength Bolting

BC 1704.3.3

Structural Cold-Formed Steel

BC 1704.3.4

Concrete – Cast-In-Place

BC 1704.4

Concrete – Precast

BC 1704.4

Concrete – Prestressed

BC 1704.4

Masonry

BC 1704.5

Wood – Installation of High-Load Diaphragms

BC 1704.6.1

Wood – Installation of Metal-Plate-Connected Trusses

BC 1704.6.2

Wood – Installation of Prefabricated I-Joists

BC 1704.6.3

Subgrade Inspection

BC 1704.7.1

Subsurface Conditions – Fill Placement & In-Place

BC 1704.7.2

Density

BC 1704.7.3

Subsurface Investigations (Borings/Test Pits)

█ TR4

BC 1704.7.4

Deep Foundation Elements

█ TR5

BC 1704.8

Helical Piles (BB # 2014-020)

█ TR5H

BC 1704.8.5

Vertical Masonry Foundation Elements

BC 1704.9

Wall Panels, Curtain Walls, and Veneers

█

BC 1704.10

Sprayed fire-resistant materials

BC 1704.11

Mastic and Intumescent Fire-resistant Coatings

BC 1704.12

Exterior Insulation and Finish Systems (EIFS)

BC 1704.13

Alternative Materials - OTCR Buildings Bulletin #

BC 1704.14

Smoke Control Systems

BC 1704.15

Mechanical Systems

BC 1704.16

Fuel-Oil Storage and Fuel-Oil Piping Systems

BC 1704.17

High-Pressure Steam Piping (Welding)

BC 1704.18

High Temperature Hot Water Piping (Welding)

BC 1704.18

High-Pressure Fuel-Gas Piping (Welding)

BC 1704.19

Structural Stability – Existing Buildings

BC 1704.20.1

Excavations—Sheeting, Shoring, and Bracing

BC 1704.20.2

Underpinning

BC 1704.20.3

BC 1814

Mechanical Demolition

BC 1704.20.4

TR1	August 2016

TR1: Technical Report

Statement of Responsibility

This form must be typewritten

3Special Inspection Categories (continued) Required for all applications, continued on page 2; █ indicates report required.

3A ← Identification of Requirement

3B Identification of

3C Certificate of Complete

3D Withdraw

Responsibilities

Inspections / Tests

Responsibilities

Y N Special Inspections

Code/Section

Initial & Date

Initial & Date

Initial & Date

Raising and Moving of a Building

BC 1704.20.5

Soil Percolation Test - Private On-Site Storm Water

█

BC 1704.21.1.2

Drainage Disposal Systems, and Detention Facilities

Private On-Site Storm Water Drainage Disposal

BC 1704.21.2

Systems, and Detention Facilities Installation

Individual On-Site Private Sewage Disposal Systems

BC 1704.22

Installation

Soil Percolation Test - Individual On-Site Private

█

BC 1704.22

Sewage Disposal Systems

Sprinkler Systems

BC 1704.23

Standpipe Systems

BC 1704.24

Heating Systems

BC 1704.25

Chimneys

BC 1704.26

Fire-resistant Penetrations and Joints

BC 1704.27

Aluminum Welding

BC 1704.28

Flood Zone Compliance (attach FEMA elevation/dry

BC 1704.29

floodproofing certificate where applicable)

BC G105

Luminous Egress Path Markings

█

TR7

BC 1704.30

BC 1024.8

Emergency and Standby Power Systems (Generators)

BC 1704.31

Post-installed Anchors (BB# 2014-018, 2014-019)

BC 1704.32

Seismic Isolation Systems

BC 1707.8

Concrete Design Mix

█

TR3

BC 1905.3

BC 1913.5

Submit TR3 to complete this item

Concrete Sampling and Testing

█

TR2

BC 1905.6

Submit TR2 to complete this item

BC 1913.10

4Progress Inspection Categories Required for all applications. █ indicates report required.

	4A ← Identification of Requirement						4B Identification of	4C Certificate of Complete		4D Withdraw
							Responsibilities	Inspections / Tests		Responsibilities
Y N Progress Inspections						Code/Section	Initial & Date	Initial & Date		Initial & Date
				Preliminary		28-116.2.1, BC 110.2
				Footing and Foundation		BC 110.3.1
				Lowest Floor Elevation		BC 110.3.2
				Structural Wood Frame		BC 110.3.3
				Energy Code Compliance Inspections	█ TR8	BC 110.3.5	Submit TR8 to complete this item
				Fire-Resistance Rated Construction		BC 110.3.4
				Public Assembly Emergency Lighting		28-116.2.2
				Final*		28-116.2.4.2, BC 110.5,
					Directive 14 of 1975, and 1 RCNY §101-10

* For column 4C, indicate date when the actual final inspection was performed

5Design Applicant’s Statements and Signatures P.E./R.A. responsible for plans, choose both below and sign/seal.

Name (please print)

I have identified all of the special inspections, progress inspections and tests

required for compliance.

SignatureDate

I certify that the Special Inspection and Approved Agencies engaged by the own- er to supervise the work specified above are acceptable. (BC 1704.1)

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

TR1 August 2016

TR1

PAGE 3

6Owner’s Statement and Signature for Progress/Special Inspector Required when inspection applicant identifies responsibilities.

I have reviewed the information provided herein and, to the best of my knowledge and belief, attest to its accuracy. I approve the identification of the responsible inspector. 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

7Inspection Applicant’s Identification of Responsibilities Check all that apply below:

For the special inspections indicated above in section 3, I certify that I am the principal/director of the special inspection agency accepting responsibility for conducting the inspections. I further certify that I have read the applicable sections of the New York City Construction Codes in connection with special inspections as well as 1 RCNY 101-06 Rule, which specifies the qualifications required for each inspection and that this agency meets those qualifications for each and every special inspection for which I/we take responsibility. I agree that both I and the agency will comply with all provisions of the New York City Construction Codes and the Rule. I am aware of the additional sanctions imposed on false filings by §28-211.1.2 of the Administrative Code.

For the progress inspections indicated above in section 4, except energy code inspections on the TR8 form, and/or concrete test items indicated in section 3, I assume the responsibility and I personally, or where permitted by the New York City Construction Codes, qualified personnel under my direct supervision, will perform the required inspections and tests on such forms and in such matter as the Department requires or requests. I am aware of the additional sanctions imposed on false filings by §28-211.1.2 of the Administrative Code.

Final Inspection:

I will make final inspection of the construction work, including those inspections during its progress necessary to my certification upon final inspection that all work substantially conforms to approved construction documents and applicable laws and rules. I will confirm that the

performance of progress inspections and other inspections has been documented before I report the work complete. As prescribed by 1 RCNY 101-10, I will perform the final inspection within 1 year from the expiration of the last valid permit of the work.

Upon completion of the work and within 30 days of my final inspection, I will file a certification attesting to the fact that all work was performed and completed in accordance with the approved construction documents, laws and rules, except as reported otherwise.

I understand that my failure to file a certification of completion or to notify the Department of my withdrawal of responsibilities within one year from expiration of the last valid permit may result in the loss of my privileges to file under Directives 2 and 14 of 1975 or issuance of a violation, or both. 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 items specified herein and I hereby state that: None of the inspections/tests indicated herein have been performed to date by the previously designated individual.

Some of the inspections/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)

TR1	August 2016