NOISE CONTROL FORM STATIONARY SOURCES
NOISE CONTROL FORM STATIONARY SOURCES Teaneck Health Department
APPLICANT: _________________________________________________ ADDRESS: ________________________________________ BLOCK: _____________ LOT: ____________ PHONE: _______________________________________ CONTRACTOR: ________________________________________________________ NAME: ____________________________________________________________ ADDRESS: _______________________________________________ PHONE: _____________________ PLANS SUBMITTED: _________________________ PROOF/EXISTING UNIT: _______________________ MANUFACTURERS SPECS: _______________________________________ SURVEY/LOCATION: ____________________________________________ TYPE OF EQUIPMENT TO BE INSTALLED: ______________________________________________________ EXTERNAL A/C COMPRESSOR: _____________________________________________________________ POOL FILTER PUMP: ______________________________________________________________________ OTHER: ________________________________________________________________________________ I hereby certify that the equipment installed at the applicant’s address in Teaneck, NJ will comply with the provisions of Article VI, Section 21-45 of the Teaneck Township code * (Noise Control from Stationary Sources) *Note: If measured sound levels do not comply, you may be required to retain an acoustical engineer. Relocation or modification of the equipment may be necessary as well as installation of sound attenuating equipment. ________________________________________________________________ Signature, Property Owner
_______________________ Date
________________________________________________________________ Signature, Contractor
_______________________ Date
Site Inspection: _____/_____/_____ Approval Date: _____/_____/_____ Inspector: ____________________________________________ Cc: Building Department
Approved/Denied: __________________
Inspector: __________________
APPLICANT: _________________________________________________ ADDRESS: ________________________________________ BLOCK: _____________ LOT: ____________ PHONE: _______________________________________ CONTRACTOR: ________________________________________________________ NAME: ____________________________________________________________ ADDRESS: _______________________________________________ PHONE: _____________________ PLANS SUBMITTED: _________________________ PROOF/EXISTING UNIT: _______________________ MANUFACTURERS SPECS: _______________________________________ SURVEY/LOCATION: ____________________________________________ TYPE OF EQUIPMENT TO BE INSTALLED: ______________________________________________________ EXTERNAL A/C COMPRESSOR: _____________________________________________________________ POOL FILTER PUMP: ______________________________________________________________________ OTHER: ________________________________________________________________________________ I hereby certify that the equipment installed at the applicant’s address in Teaneck, NJ will comply with the provisions of Article VI, Section 21-45 of the Teaneck Township code * (Noise Control from Stationary Sources) *Note: If measured sound levels do not comply, you may be required to retain an acoustical engineer. Relocation or modification of the equipment may be necessary as well as installation of sound attenuating equipment. ________________________________________________________________ Signature, Property Owner
_______________________ Date
________________________________________________________________ Signature, Contractor
_______________________ Date
Site Inspection: _____/_____/_____ Approval Date: _____/_____/_____ Inspector: ____________________________________________ Cc: Building Department
Approved/Denied: __________________
Inspector: __________________
