Issued: 5/2020 Replaces: 7/2015
Previous Version Obsolete
U.S. Department of the Interior
(Attachment A)
Deputy Assistant Secretary – Indian Affairs (Management)
Office of Facilities, Property and Safety Management
Division of Safety and Risk Management
Request for Final Inspection/Re-Inspection and Certificate of Occupancy Form
Submit this Form and ALL Required Documentation to Division of Safety and Risk Management (DSRM)
Site Name: ____________________________________________________________ IA-FMS Site ID: __________________________
Project Description: _____________________________________________________ Project No: ______________________________
IA POC, IA, BIA or BIE Project Manager: ____________________________________ Telephone No.: ___________________________
eMail Address: ______________________________________________ Proposed Date for Inspection: __________________________
Required documentation as listed in the Final Inspection and Certificate of Occupancy Guidelines, Appendix 1. If work
has not been completed by the requested inspection date, the inspection will not be scheduled.
The following required documentation, as applicable, is hereby submitted to the Division of Safety and Risk Management,
as the Authority Having Jurisdiction.
Automatic Sprinkler Protection System Stationary Fire Pump
(NFPA 13 - Standard for the Installation of Sprinkler Systems) (NFPA 20 - Installation of Stationary Pumps)
Clean Agent Fire Extinguishing System Hydrants
(NFPA 2001 - Clean Agent Fire Extinguishing Systems) (NFPA 291 - Fire Flow Testing and Marking of Hydrants)
Wet Chemical System Acceptance Report Asbestos
(NFPA 17A - Standard for Wet Chemical Extinguishing Systems) (40 CFR - Protection of the Environment, Part 763)
Fire Detection Alarm System Emergency and Standby Power Systems
(NFPA 72 - National Fire Alarm and Signaling Code) (NFPA 110 - Emergency and Standby Power Systems)
Emergency Systems Folding and Telescopic Seating
(NFPA - 70 National Electrical Code) (NFPA 102 - Grandstands, Folding and Telescopic Seating,
Tents, and Membrane Structures)
Hydraulic/Electric Elevator System
(ASME A17.1/CSA B44 Handbook)
In addition to the above, Operation and Maintenance Manuals for all equipment are on site and there is an approved copy of design plans
and specifications available at the job site. I hereby certify that all construction work for this project is complete and that the
above required documentation, as applicable, is submitted with this request form to the Division of Safety and Risk
_______________________________________________________ ________________________________
Signature of IA POC, BIA or BIE Project Manager Date
This section for Division of Safety and Risk Management Use Only
___________________________________ _____________________________________________
Scheduled Date Assigned Inspector
___________________________________ Final Inspection
Scheduled Time
Re-Inspection: 1
___ 2nd ___ 3rd ___
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