Fillable FIRE-RATED JOINT AND PENETRATION(S) AFFIDAVIT (City of Pompano Beach)

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FIRE-RATED JOINT AND PENETRATION(S) AFFIDAVIT (City of Pompano Beach)

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City of Pompano Beach
Department of Development Services
Building Inspections Division
STATE OF ________________
COUNTY OF _______________
Sworn to (or affirmed) and subscribed before me this _____ day of
______________, 20_______ by:
_________________________________________________
(NOTARY’S SIGNATURE as to Qualifier)
Notary Name ______________________________________
(Print, Type or Stamp Notary’s Name)
Personally Known _____ or Produced Identification _____
Type of Identification Produced: _______________________________
NOTARY SEAL
FIRE-RATED JOINT AND PENETRATION(S) AFFIDAVIT
Permit No:
Project Name:
Project Address:
I,
__________________________________, the qualifying agent for the company noted below, HEREBY CERTIFY that all
penetrations through walls, ceilings, floors and other barriers resulting from the passage of pipes, conduits, bus ducts, cables, wires,
air ducts, pneumatic ducts and penetrations from similar building service equipment installed in connection with the above permit
have been protected by approved fire rated materials or assemblies meeting the acceptance criteria of AMERICAN SOCIETY FOR
TESTING AND MATERIALS (ASTM) E814, or UNDERWRITERS’ LABORATORIES (UL) 1479, or other approved testing standard, and have
been installed by qualified persons in accordance with the manufacturer’s specifications, and are in compliance with the Florida
Building Code and Plans Reviewed by the City of Pompano Beach.
I FU
RTHER CERTIFY that all joints installed in or between fire-resistance rated walls, floor or floor/ceiling assemblies and roofs or
roof/ceiling assemblies have been protected by an approved fire-resistant joint system meeting the acceptance criteria of ASTM
E1966, or UL 2079, or other approved testing standard.
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FIRE-RATED JOINT AND PENETRATION(S) AFFIDAVIT (City of Pompano Beach)

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Completed 4 August 2020

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