Fillable Town of Brookhaven Long Island SOLDER CERTIFICATION AND (Town of Brookhaven)

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Town of Brookhaven Long Island SOLDER CERTIFICATION AND (Town of Brookhaven)

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Town of Brookhaven
Long Island
Building Division
Beth Reilly, Esq., Commissioner
Tara McLaughlin, Deputy Commissioner
Angus Graham, Chief Building Inspector
One Independence Hill, Farmingville, NY 11738 • Phone 631-451-6333 • Fax 631-451-6341
SOLDER CERTIFICATION AND ANTI-SCALD CERTIFICATION
Building Permit No. __________________________ Date: ______________________________
Address: _____________________________________________________________________________
Owner: ______________________________________________________________________________
Tax Map Number:_____________________________________________________________________
Plumber: _____________________________________________________________________________
I certify that the solder used in the water supply and distribution system contains less than 2/10 of 1% lead
as required in section 605.15.3 of the Plumbing Code of New York State.
I certify that the water distribution system was installed without the use of any soldered joints.
I certify that I installed an anti-scald and/or thermal shock preventing device at all bathing and/or
showering fixtures in conformance with section 424.4 of the Plumbing Code of New York State to mitigate
the potential hazards due to shower valves that allowed surges of high temperature water to flow from the
showerhead.
Please Check One.
I certify I am the licensed plumber (License # _____________________) that installed all of the plumbing
for the above referenced building permit.
I certify I am the homeowner and I personally installed all the plumbing for the above referenced building
permit. * Applicable only for one & two family dwellings. (Not for Commercial use.)
State of New York, County of _______________________
On this __________ day of _______, 20 ________, before me came ____________________________________________,
to me known to be the individual described in and who executed the forgoing instrument, and acknowledged that
he/she executed the same.
Plumber or Homeowner Signature
Notary Public State of New York
(Please Print)
(Please Print)
(Please Print)
I affirm that all information provided in this document is true and factual.
False statements made herein are punishable as a Class “A” misdemeanor pursuant to Section 210.45 of the Penal Law.
2-2015
Town of Brookhaven
Long Island
Building Division
Beth Reilly, Esq., Commissioner
Tara McLaughlin, Deputy Commissioner
Angus Graham, Chief Building Inspector
One Independence Hill, Farmingville, NY 11738 • Phone 631-451-6333 • Fax 631-451-6341
GAS SUPPLY LINE TEST CERTIFICATION
Building Permit No. __________________________ Date: _____________________________
Job Site Address: ______________________________________________________________________
Owner: ______________________________________________________________________________
Plumber: _____________________________________________________________________________
I certify that the Gas supply lines have been installed and tested in accordance with the Fuel Gas Code of New York
State including section 404 and 406.
Installation:
Residential Installation
Commercial Installation
Please Check Combustion Appliance Installed:
Heating Equipment Kitchen Range
Hot Water Heater Other ________________
Fireplace/Stove Other ________________
Test Pressure: ____________________ Test Duration: ___________________ Pass Fail
Comments: ___________________________________________________________________________________
I certify I am the licensed plumber (License # ________________) that installed all Gas supply lines on the above
referenced premises.
Plumber Signature
State of New York, County of ___________________________
On this __________ day of _______, 20 ________, before me came ____________________________________________,
to me known to be the individual described in and who executed the forgoing instrument, and acknowledged that
he/she executed the same.
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Notary Public State of New York
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(Please Print)
(Please Print)
(Please Print)
I affirm that all information provided in this document is true and factual.
False statements made herein are punishable as a Class “A” misdemeanor pursuant to Section 210.45 of the Penal Law.
2-2014
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Town of Brookhaven Long Island SOLDER CERTIFICATION AND (Town of Brookhaven)

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Completed 2 August 2020

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