FP-02 rev. 01/17
Division of Fire Prevention
One Independence Hill, Farmingville, 11738
(631) 451-6262 FAX: (631) 451-6283
Certication of Inspection and Testing
of Fire Alarm System
F.M. Use ONLY
OK NOT OK
FM
Date:
1. NAME OF PREMISE:
2. ADDRESS OF PREMISE:
3. FIRE DISTRICT AS LISTED ON CENTRAL STATION RECORDS:
4. NAME OF OWNER/OCCUPANT AGENT PRESENT:
5. TYPE OF SYSTEM: (MANUAL, AUTOMATIC, VOICE EVACUATION, ETC.)
6. IS OCCUPANCY TYPE SAME AS PREVIOUS TEST?
11.
Were all deciencies noted above corrected?
Yes
No If not, why:
12. NAME OF INSPECTING FIRM:
13. ADDRESS OF INSPECTING FIRM:
14. NYS ALARM LICENSE #: 15. EXPIRATION DATE:
16. PHONE NUMBER OF INSPECTING FIRM: 17. DATE OF INSPECTION:
18. PRINT NAME OF tECHNICIAN:
19. SIGNATURE OF TECHNICIAN:
CERTIFICATION: I, an employee of the Inspecting Firm listed above, do hereby certify that the re alarm
system described above was inspected in accordance with the applicable portions of NFPA 72 (current
NYSFP&BC reference standard edition) and Brookhaven Town Local Law. This Certication does not
imply that items requiring daily, weekly, monthly or quarterly inspection or testing were performed at the
specied intervals, but does imply that all such items were inspected or tested and appeared to function
as noted in this certication at the time of the inspection. I certify that this inspection has been properly
conducted and all of the above statements are true and correct to the best of my knowledge.
P L E A S E T Y P
E O R P R I N T C L E A R L Y
CAUTION: NOTIFY ALL OCCUPANTS AND ANY AGENCIES WHO MIGHT RESPOND
BEFORE TESTING SYSTEM. FAILURE TO DO SO MAY RESULT IN LEGAL
ACTION AGAINST THE TECHNICIAN AND /OR THE INSPECTION FIRM.
ANY FALSE STATEMENT MADE HEREIN IS PUNISHABLE AS A MISDEMEANOR PURSUANT TO SECTION 210.45 OF
THE NEW YORK STATE PENAL LAW.
FORM WITH AN ORIGINAL SIGNATURE IS REQUIRED! DO NOT SEND BY FAX!
(This form does not need to be notarized.)
7. NAME OF CENTRAL STATION:
8. CENTRAL STATION PHONE NUMBER:
9.
List deciencies noted or check box if no decienies noted:
Please Note: Lack of Carbon Monoxide detection in compliance with Brookhaven Town Code Chapter 30, Article XXX Sections 173 through
183 shall be considered a deficiency and shall be noted in the deficiencies section above by the inspector completing this form.
10.
Carbon Monoxide detection present in compliance with Brookhaven Town Code? Yes No
19. DATE:
