The Backflow Prevention Device Exemption Form for a Residential Building with One Domestic Line Only is a letter template used with the NYC Department of Environmental Protection (DEP) Cross-Connection Control Review Unit. A Professional Engineer (PE) or Registered Architect (RA) types it on letterhead to show that a residential building with a single domestic water service line qualifies for exemption from containment backflow prevention requirements. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the original is published by NYC DEP at the official URL below.
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What is Backflow Prevention Device Exemption Form for a Residential Building with One Domestic Line Only – New York City, NY?
This form is a letter template that a Professional Engineer (PE) or Registered Architect (RA) types on letterhead to request, from the NYC Department of Environmental Protection (DEP), an exemption from containment backflow prevention.
The Backflow Prevention Device Exemption Form for a Residential Building with One Domestic Line Only (printed on the PDF as "Form for Backflow Prevention Assembly Exemption for a residential building with one Domestic Line only") is a sample letter addressed to the DEP Bureau of Water & Sewer Operation, Cross-Connection Control Review Unit. The PE or RA fills in the bracketed items for the building concerned: the property address, block, lot and county, whether the building is existing, being renovated or future, the number of stories and dwelling units, and the size of the single domestic water service line.
The letter lists 24 conditions the building must NOT have, such as a swimming pool, an irrigation system, a booster pump, a water storage tank, commercial use or multiple domestic water service lines. It ends with the PE or RA's statement that, after inspection, the building is rated non-hazardous and qualifies for exemption, and with signature blocks for the property owner and for the PE or RA.
DEP explains that backflow prevention devices keep contaminated water from flowing backwards into the public water supply. DEP lists this form among the exemption forms for trade professionals; a separate self-certification exemption form for one domestic service line also exists on the same DEP page.
Who needs to file Backflow Prevention Device Exemption Form for a Residential Building with One Domestic Line Only – New York City, NY?
The form is used by Professional Engineers (PE) and Registered Architects (RA) who apply to DEP for a backflow prevention device exemption for a facility with one domestic service only. The property owner also provides a name, mailing address and phone number and signs the letter.
It fits a residential building that meets ALL the conditions in the sample letter: it is supplied by only one dedicated domestic water service line (or one branched off a fire service), and it contains none of the listed items. Those items include air conditioning with chilled or condenser water, a booster or fill pump, a chemically treated boiler, a large boiler (350,000 BTU or more), an irrigation system or hose bibb connection, a pressure tank, a private well or water re-use, a swimming pool, a water storage tank and commercial use.
Do not use this form if the building has any listed item or more than one domestic water service line. DEP's page lists premises with multiple water service lines, in-ground irrigation sprinklers and swimming pools among those that must install a device unless DEP grants a specific exemption. If you are unsure whether your property needs a device, DEP says to call 311.
When to file Backflow Prevention Device Exemption Form for a Residential Building with One Domestic Line Only – New York City, NY
Submit the letter when a PE or RA is requesting DEP's review of a residential building's containment backflow prevention requirements and has confirmed the building meets every condition in the sample letter. The letter covers four situations: an existing building with existing service, an existing building with new service, a building being renovated, or a future building. The form prints no filing deadline or processing time.
The exemption depends on the conditions staying true. In the letter, the PE and RA acknowledge that if any of the listed conditions change, installing an appropriate backflow prevention assembly may become mandatory.
How to fill out Backflow Prevention Device Exemption Form for a Residential Building with One Domestic Line Only – New York City, NY
Prepare PE or RA letterhead
The letter goes on the letterhead of the PE or RA. Leave the area marked "(For Department Use Only)" blank, and enter the date at "(Date):".
Enter the property location
Under "Re:", write the building's Address, Block, Lot and County.
State the building's status
Choose the phrase that fits: existing building with existing service, existing building with new service, building being renovated, or future building.
Describe the building and water service
Enter the number of stories, whether there are underground levels, the number of residential dwelling units and the size in inches of the single domestic water service line. Add a brief description of the general use of the water system.
Confirm the list of excluded items
The letter states the building contains none of the 24 listed items. Confirm each one through your inspection or assessment before keeping this statement.
Complete the assessment statement
Choose existing or new building in the sentence about the inspection or assessment, which states the building is rated non-hazardous and qualifies for exemption.
Add the property owner's details
Enter the owner's name, mailing address and phone number, and have the owner sign.
Add the PE or RA details
Enter the PE or RA name, plus license number and phone number if they are not on the letterhead. Apply the NYS PE/RA stamp and signature.
Review and download the completed PDF
Check that no point of the letter was omitted, then download or print the completed PDF from FillingPDF and send it as described under How to submit.
How to submit Backflow Prevention Device Exemption Form for a Residential Building with One Domestic Line Only – New York City, NY
The form names one destination: the DEP Cross-Connection Control Unit, which reviews the letter and approves it. The letter's header gives the address:
- Addressee: NYC Department of Environmental Protection, Bureau of Water & Sewer Operation, Cross-Connection Control Review Unit, 59-17 Junction Blvd. 3rd Floor Low-rise, Flushing, NY 11373.
- What to send: the typed letter on PE or RA letterhead, with every point of the sample letter included and the bracketed items replaced with information for the building. It must carry the owner's signature and the NYS PE/RA stamp and signature.
- Getting the form by mail: DEP says to call 311 to request backflow prevention forms by mail.
The form does not describe an online, e-mail or in-person channel, and it states no fee. For any question about requirements, call 311 and ask to be directed to DEP. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Handwriting the letter instead of typing it; the form says to TYPE the letter on PE/RA letterhead.
- Omitting any point of the sample letter; the form says not to omit any of the points.
- Leaving the bracketed items, such as building status, story count, dwelling units or service line size, unreplaced with the building's own information.
- Using the exemption for a building that has any listed item, such as a pool, booster pump, water storage tank, commercial use or multiple domestic water service lines.
- Leaving out the PE/RA license number and phone number when they are not printed on the letterhead.
- Sending the letter without the owner's signature or without the NYS PE/RA stamp and signature.
- Addressing the letter elsewhere instead of the Cross-Connection Control Review Unit, 59-17 Junction Blvd. 3rd Floor Low-rise, Flushing, NY 11373.
- Treating the exemption as permanent when building conditions change; a device may then become mandatory.
Frequently asked questions
What is the backflow prevention exemption form for a residential building?
It is a letter template a PE or RA types on letterhead to ask NYC DEP for an exemption from containment backflow prevention for a residential building with one domestic water service line. The letter confirms the building has none of the listed risk items.
Who can submit the backflow exemption form in NYC?
DEP says PEs or RAs use this form to apply for an exemption for a facility with one domestic service only. The owner provides contact details and signs, but the letter carries the NYS PE/RA stamp and signature.
Which buildings do not qualify for this exemption?
Buildings with any of the listed items, such as a swimming pool, irrigation system or hose bibb connection, booster pump, water storage tank, commercial use or multiple domestic water service lines. The letter must say the building contains none of them.
Where do I send the backflow prevention exemption letter?
Send it to the NYC DEP Bureau of Water & Sewer Operation, Cross-Connection Control Review Unit, 59-17 Junction Blvd. 3rd Floor Low-rise, Flushing, NY 11373. The form names no other submission channel.
What happens if conditions in the building change after the exemption?
The letter states that if any of the listed conditions change, installing an appropriate backflow prevention assembly may become mandatory. The PE and RA acknowledge this when they sign.
What is the difference between this form and the self-certification exemption form?
This form is a letter submitted to the Cross-Connection Control Unit for approval. DEP also lists a Self-Certification Exemption Form: One Domestic Service Line Only, which PEs or RAs use to self-certify that such a facility needs no device.
Can I fill out the backflow exemption form online?
Yes. You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service, not affiliated with NYC DEP, and does not submit the letter; it goes to DEP through the channel described under How to submit.
Is this an NYC property tax form?
No. It is an NYC DEP water form about backflow prevention, not a property tax form. The letter does ask for the building's block, lot and county, which identify the property for the review.
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