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CITY OF ALBANY DEPARTMENT OF BUILDINGS & REGULATORY COMPLIANCE 200 Henry Johnson Boulevard Albany, NY 12210 Phone (518) 434-5165 Fax (518) 434-6015 GRIEVANCE FORM This form provides you with an opportunity to formally dispute a lack of action by BRC or action taken by BRC. It is important to fill out this form so as to give BRC staff an opportunity to research your situation. When completed please forward this form to Buildings & Regulatory Compliance, 200 Henry Johnson Blvd, Albany, NY 12210 or to [EMAIL REDACTED]. Once we have reviewed your grievance we will notify you of our decision. Unless this grievance is already the subject of a Final Determination Letter, at that time you may request a meeting with BRC staff to explain your grievance. Thereafter a Final Determination Letter will be issued setting out the reason(s) for our decision to uphold or deny your grievance. A Final Determination Letter finally decides the matter with respect to the Department’s authority. CONTACT INFORMATION EMAIL: PHONE HOW MAY CONTACT YOU?: MAIL EMAIL TELEPHONE (CHECK ALL THAT APPLY) CONCERN/GRIEVANCE RELEVANT ADDRESS: (IF APPLICABLE) NARRATIVE: INSTRUCTIONS: PLEASE DESCRIBE THE NATURE OF YOUR GRIEVANCE. BE SURE TO INCLUDE THE NAMES, DATES, AND PLACES INVOLVED TO THE BEST OF YOUR ABILITY. PLEASE FEEL FREE TO APPEND ANY AND ALL DOCUMENTS, STATEMENTS, CORRESPONDENCE, ETC. THAT YOU THINK WOULD ASSIST BRC STAFF TO ADDRESS YOUR SITUATION OR TO DRAFT YOUR NARRATIVE IN WHATEVER FORM YOU PREFER. STAFF USE ONLY DATE REC’D: REC’D BY: SCANNED BY: REC. NO.: BRC Form 08 Rev’d: 2/2016 Page 1 of 2 ---PAGE BREAK--- NARRATIVE (CONT.) WHAT RELIEF ARE YOU REQUESTING (WHAT WOULD YOU LIKE TO SEE HAPPEN)? IF THIS IS NOT DONE, WOULD YOU LIKE THE OPPORTUNITY TO MEET WITH BRC STAFF TO FURTHER DISCUSS THIS MATTER? YES NO ARE YOU REQUESTING A FINAL DETERMINATION LETTER? YES NO NOTE: IF YOU HAVE REQUESTED A STAFF MEETING, YOUR FINAL DETERMINATION LETTER WILL NOT BE ISSUED UNTIL AFTER THAT MEETING IS HELD. BRC Form 08 Page 2 of 2