3rd_party_request

Department of Consumer & Regulatory Affairs

Building and Land Regulation Administration

941 North Capitol Street, NE

Washington, DC 20002

Third Party Request Form

(Request form must be approved before engaging in Third Party Inspection)

Form ID#

In order to submit this form, you must fill out all of the fields. If you do not receive a "Thank You" page, please go back and check the information you entered. The office will notify you if any action will be taken.

1. Owner/Management Company Name

4. Date of Request

2. Address

5. Telephone

Fax

3. City

State

Zip

6. Email Address

7. Owner/Management Company Representative

10. Name of Agency

8. Project Name

11. Name of Agent

9. Project Address (please indicate suite #)

12. Telephone

Fax

13. Indicate Building Trade(s) for which Third Party Inspections will be used:

Electrical

Elevators

Plumbing

Fire

Mechanical (HVAC)

Construction

14. Name of Proposed Third Party Inspection Agency

15. Indicate the Type of Inspection(s):

Final

Other

16. Date of Inspection

17. Permit #(s) for All requested trades

18. Has a BLRA Inspector from the trade indicated above previously conducted inspections at the site?

Yes

If yes, provide the inspection name and the last inspection date:

19. Are there any violations currently at the site?

Yes

20. By submitting this form, I certify that the above statements on this application are true and complete to the best of my knowledge and belief. I agree to comply with all applicable laws and regulations of the District of Columbia. Signature by a Third Party Inspection Agency as an agent indicates a contractual relationship between the agency and the building owner. The making of false statements on this application is punishable by criminal penalties (DC CODE SEC. 22−2514)

Name of Owner/Management Company Officer

Name of Agent

Date