Date Received

Control #
FIRE PROTECTION SUBCODE
TECHNICAL SECTION Date Issued
Permit #
A. IDENTIFICATION—APPLICANT: COMPLETE ALL APPLICABLE INFORMATION. WHEN CHANGING C. CERTIFICATION IN LIEU OF OATH
CONTRACTORS, NOTIFY THIS OFFICE. CALL UTILITY DIG NO: 1-800-272-1000. I hereby certify that I am the (agent of) owner of record and am authorized to make this
Block Lot Qualification Code application.
Work Site Location Applicant/Contractor
sign here:
Owner in Fee: Print name here:
Tel. e-mail [ ] Certified Contractor [ ] Exempt Applicant
D. TECHNICAL SITE DATA
Address DESCRIPTION OF WORK:
street municipality zip code
Contractor: Tel. Water Supply Source
Address e-mail Method of Alarm/Suppression System Supervision _____________________

NUMBER 1234567890123456
FEE (Office Use Only)
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Fire Protection Equipment, NJ Div of Fire Safety Permit No. Flammable/Combustible Tanks $ 1234567890123456
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Fire Protection Equipment, NJ Div of Fire Safety Installer No. Alarm Systems 1234567890123456
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Fire Alarm Contractor No. Exp. Date [ ] System 1234567890123456
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Home Improvement Contractor Registration No. or Exemption Reason
[ ] 110v Interconnected 1234567890123456
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[ ] CO Detectors/110v
Federal Emp. ID No. FAX: 1234567890123456
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Alarm Devices (i.e., smoke, heat, pulls,
B. FIRE PROTECTION CHARACTERISTICS water/flow)
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Fuel Storage Tank: Supervisory Devices (i.e., tampers, low/high air) 1234567890123456
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Use Group: Present Proposed
Fuel Type: [ ] Flammable OR [ ] Combustible 1234567890123456
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Signaling Devices (i.e., horn/strobes, bells)
Constr. Class: Present Proposed Capacity 1234567890123456
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Other Devices
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Heating System: [ ] New [ ] Modification to Existing Fire Alarm System: [ ] New [ ] Existing 0 1234567890123456
OR OR TOTAL
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OR [ ] Conversion OR [ ] Replacement Location of Panel: Suppression Systems 1234567890123456
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Fire Suppression/Standpipe System: Fire Pump GPM Type 1234567890123456
Fuel Type: [ ] Gas [ ] Oil [ ] Electric [ ] Solar 1234567890123456
[ ] Other
[ ] New OR [ ] Existing Dry Pipe/Alarm Valves 1234567890123456
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Location of Main Control Valve: Pre-action Valves 1234567890123456
Location: 1234567890123456
Total Cost of Fire Protection Work $
Sprinkler Heads (Dry and Wet) 1234567890123456
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Standpipes 1234567890123456
JOB SUMMARY (Office Use Only) INSPECTIONS Dates (Month/Day)
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PLAN REVIEW
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Type: Failure Failure
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Approval Initial Wet Chemical 1234567890123456
[ ] No Plans Required
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Alarm System Dry Chemical 1234567890123456
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[ ] Partial -Underslab Utilities Approved
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12345678901234567890123456789012123456789012345678901234567890121234567890 CO2 Suppression 1234567890123456
Date: Approved by:
Suppression Sys.
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Standpipe
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Foam Suppression 1234567890123456
[ ] Fire Protection Plans Approved
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Date: Fire Pump FM200 Suppression 1234567890123456
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Approved by:
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Pre-Eng. System
Other 1234567890123456
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Joint Plan Review Required:
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Other Systems 1234567890123456
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Mechanical Kitchen Hood Exhaust System
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[ ] Bldg. [ ] Elec. [ ] Plumb. [ ] Elev.
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SUBCODE APPROVAL for PERMIT Smoke Control
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Smoke Control System 1234567890123456
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Date: TCO
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Fuel-Fired Appliances [ ] Gas [ ] Oil [ ] Solid 1234567890123456
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Approved by:
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Flam/Combust Tanks Fireplace Venting/Metal Chimney 1234567890123456
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SUBCODE APPROVAL for CERTIFICATE Fireplace Venting Other 1234567890123456
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12345678901234567890123456789012123456789012345678901234567890121234567890 Administrative Surcharge $1234567890123456
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[ ] CO [ ] CCO [ ] CA Final
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Date: Minimum Fee $1234567890123456
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Other 1234567890123456
State Permit Surcharge Fee $1234567890123456
Approved by:
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U.C.C. F140 (rev. 02/11) Applicant: When submitting this form to your Local Construction Code Enforcement Office, please provide one
TOTAL FEE $1234567890123456
Internet version original plus three photocopies.