Form 482-0651 Final Occupancy Checklist Certifications for Request of Inspection - Illinois

Form 482-0651 is a Illinois Department of Public Health form also known as the "Final Occupancy Checklist Certifications For Request Of Inspection". The latest edition of the form was released in August 1, 2018 and is available for digital filing.

Download a PDF version of the Form 482-0651 down below or find it on Illinois Department of Public Health Forms website.

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Final Occupancy Checklist Certifications for Request of Inspection
IDPH number
Date submitted
Facility name and city
Brief narrative of
project
Name & title of individual submitting inspection request
The following information must be submitted and accepted prior to an on-site inspection. Inspections will be scheduled in
accordance with the Illinois Hospital Licensing Act and Requirements, the Illinois Ambulatory Surgical Treatment Center
Licensing Act and Requirements, or the Illinois Nursing Home Act and Codes. All information shall be submitted
together unless the requested certifications are not applicable to the project. If not applicable to the project,
indicate this on the space provided (N/A, why?). Certification letters and forms shall contain a signature, typed
names will not be accepted.
Architect, Engineer, Contractors Certifications
Enclosed, if N/A explain
Architect’s authorization for 95 percent payment of all construction. Submit a
1a
completed AIA G702, Application and Certificated for Payment Form.
Enclosed, if N/A, explain
Punch list of incomplete items,include date punch list was performed.
1b
Signed certification from the licensed architect/engineer of record and contractor
Enclosed, if N/A explain
that they have reviewed all of the certifications and the project is completed in
1c
accordance with approved plans and applicable codes.
Electrical
Signed certification by the installer that the elevator recall system is installed
Enclosed, if N/A explain
and operates in accordance with ANSI A17.1,(2007) Safety Code for Elevators
2a
and Escalators.
Enclosed, if N/A explain
2b
Signed certification by the installer that the nurse call system has been installed,
tested and found to operate in accordance with the specifications.
Signed certification by the electrical system installer that the electrical systems
Enclosed, if N/A explain
have been installed and all electrical work has been performed in accordance
2c
with NFPA 70.
Signed certification by the installer that the emergency generator has been
Enclosed, if N/A explain
installed to meet the licensure standards, NFPA 99 Health Care Facilities, 2012
Edition and NFPA 110 Emergency and Standby Power Systems, 2010 Edition.
2d
The generator must be operational for the inspection. Include initial four-hour
acceptance test and certification of 10 seconds or less transfer time.
Signed certification by the installer that the installation and testing of ground-
Enclosed, if N/A explain
fault protection in electrical switches is in compliance per NFPA 70-230-95 (c)
2e
and NFPA 70-517.17 (c), 2011 edition.
Enclosed, if N/A explain
Fire Alarm System, Record of Completion Form as required by NFPA 72, 2010
2f
Edition. Available at www.nfpa.org.
Final Occupancy Checklist Certifications for Request of Inspection
IDPH number
Date submitted
Facility name and city
Brief narrative of
project
Name & title of individual submitting inspection request
The following information must be submitted and accepted prior to an on-site inspection. Inspections will be scheduled in
accordance with the Illinois Hospital Licensing Act and Requirements, the Illinois Ambulatory Surgical Treatment Center
Licensing Act and Requirements, or the Illinois Nursing Home Act and Codes. All information shall be submitted
together unless the requested certifications are not applicable to the project. If not applicable to the project,
indicate this on the space provided (N/A, why?). Certification letters and forms shall contain a signature, typed
names will not be accepted.
Architect, Engineer, Contractors Certifications
Enclosed, if N/A explain
Architect’s authorization for 95 percent payment of all construction. Submit a
1a
completed AIA G702, Application and Certificated for Payment Form.
Enclosed, if N/A, explain
Punch list of incomplete items,include date punch list was performed.
1b
Signed certification from the licensed architect/engineer of record and contractor
Enclosed, if N/A explain
that they have reviewed all of the certifications and the project is completed in
1c
accordance with approved plans and applicable codes.
Electrical
Signed certification by the installer that the elevator recall system is installed
Enclosed, if N/A explain
and operates in accordance with ANSI A17.1,(2007) Safety Code for Elevators
2a
and Escalators.
Enclosed, if N/A explain
2b
Signed certification by the installer that the nurse call system has been installed,
tested and found to operate in accordance with the specifications.
Signed certification by the electrical system installer that the electrical systems
Enclosed, if N/A explain
have been installed and all electrical work has been performed in accordance
2c
with NFPA 70.
Signed certification by the installer that the emergency generator has been
Enclosed, if N/A explain
installed to meet the licensure standards, NFPA 99 Health Care Facilities, 2012
Edition and NFPA 110 Emergency and Standby Power Systems, 2010 Edition.
2d
The generator must be operational for the inspection. Include initial four-hour
acceptance test and certification of 10 seconds or less transfer time.
Signed certification by the installer that the installation and testing of ground-
Enclosed, if N/A explain
fault protection in electrical switches is in compliance per NFPA 70-230-95 (c)
2e
and NFPA 70-517.17 (c), 2011 edition.
Enclosed, if N/A explain
Fire Alarm System, Record of Completion Form as required by NFPA 72, 2010
2f
Edition. Available at www.nfpa.org.
Mechanical Certifications
Non-Flammable Medical Gas and Vacuum Systems Certification. Submit a complete
Enclosed, if N/A explain
3a
copy of third-party certification per NFPA 99, 2012 Edition, System Verification.
Signed certification by the installer that the sprinkler system is installed as required by
Enclosed, if N/A explain
NFPA 13, Chapter 10, NFPA 20, Chapter 14 and NFPA 14 Chapter 11. Submit a copy
3b
of the sprinkler Contractor's Material and Test Certificate for Aboveground/Underground
Piping.
Signed certification by the installer that the HVAC system has been installed and is
operating in compliance with the design plans and specifications, NFPA 90A/90B and
Enclosed, if N/A explain
3c
the Illinois Hospital Licensing Act and Requirements, the Illinois Ambulatory Surgical
Treatment Centers Licensing Act and Requirements or the Illinois Nursing Home Care
Act and codes.
Signed certification by the installer that other fire extinguishment systems (halon, for
Enclosed, if N/A explain
3d
example) have been tested and checked for the purpose of determining compliance
with the appropriate NFPA standard for the system being used.
Enclosed, if N/A explain
Signed documentation by the installer that all fire extinguishers have been checked and
3e
inspection tags are dated and attached to each device.
Signed documentation by the installer that range hood and duct systems are installed
Enclosed, if N/A explain
and operate in accordance with NFPA 96, Ventilation Control and Fire Protection of
3f
Commercial Cooking Operations, 2011 Edition.
Enclosed, if N/A explain
Signed certification by the installer that the smoke control system has been tested and
3g
operates as designed per NFPA 92, 2012 Edition.
Signed certification by the installer and test data verifying that the fire pump and
Enclosed, if N/A explain
systems components have been installed and tested per NFPA 20, Chapter 14
3h
Acceptance Testing, Performance & Maintenance and NFPA 25, Chapter 5, 5-3.3.4,
Emergency Power Operation and Chapter 9 Back-Flow Preventers.
Enclosed, if N/A explain
Signed certification by the installer and testing of each fume hood per NFPA 45 and
3i
ASHRAE HVAC Application Handbook specific to each classification.
Signed certification by the installer and testing of each biohazard cabinet per NFPA 45,
Enclosed, if N/A explain
3j
and ASHRAE HVAC Application Handbook specific to each classification.
Plumbing report which contains the name, signature and Illinois license number of the
Enclosed, if N/A explain
3k
plumbing inspector, type of inspections completed (underground, roughed-in, final) and
the plumbing installation meets the requirements of the Illinois Plumbing Code.
Matrices
UL assembly ratings
4A
Enclosed, if N/A explain
4B
Through wall/floor penetrations
Enclosed, if N/A explain
Enclosed, if N/A explain
4C
Interior finishes
Project cost and fee verification - Required for all projects
4D
Enclosed, if N/A explain
4E
Smoke and fire dampers
4F
Enclosed, if N/A explain
Ventilation balancing
Form # 482-0651 rev 108-2018

Download Form 482-0651 Final Occupancy Checklist Certifications for Request of Inspection - Illinois

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