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City of Albany Division of Buildings & Regulatory Compliance City Hall – Room 303 Albany, NY 12207 (518) 434-5165 Fax (518) 434-6015 This form must be filled out by a licensed Fire Alarm Installer when the alarm system is in full compliance and returned to the Division of Buildings & Regulatory Compliance. A separate form must be submitted for each Alarm System. Date: Permit No.: License No.: License Holder: Phone No.: Person Performing Test: Address of Certification: Owner Name: Phone No.: Owner Address: (including city, state & zip) This is to certify that the fire alarm system, which has been installed or worked on by the above applicant, located at the above referenced address in the City of Albany, NY, has been inspected and found to be in compliance with all NYS Building Code & referenced standards, and is in full operation. All applicable items or devices listed below have been checked and tested for proper operation, placement listed below and initialed by the person performing the test. An accurate count of such devices is also listed. If the items are not applicable they have been marked as such (N/A) and initialed. Item/Device Amount Initial Smoke Detectors Pull Stations Fan Shut Down Elevator Recall Sprinkler Alarms Smoke & Fire Dampers Auto Dialer (if no auto dialer – system must be labeled “LOCAL ALARM ONLY – For Emergency Dial 911” Circle One Bells Strobes Horns Chimes Battery Condition Speakers Duct Detectors Heat Detectors All areas have proper decibel levels All magnetic door holders release on alarm All sub-panels report back to the main panel Annunciation Location Labels Installed & Checked Suppression System connected to Fire Alarm Panel - Please continue to the reverse side – ---PAGE BREAK--- List all items installed or checked that are not listed above: Item/Device Amount Initial List any items which do not comply with NYS Building Code & referenced standards: Item/Device Amount Initial Has current annual NFPA required certification test been completed? Yes No If no, building does not comply and certification cannot be accepted. I hereby certify that I have read the instructions and examined this form and know the same to be true and correct. Signature of Person Performing Test Date Signature of License Holder Date