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City of Albany Department of Buildings & Regulatory Compliance 200 Henry Johnson Blvd. – Suite 1 Albany, NY 12210 Phone: (518) 434-5165 Fax: (518) 434-6015 www.albanyny.gov SPRINKLER REGISTRATION FORM This form must be filled out completely and legibly. Building Address OFFICIAL USE ONLY 2016 Owner of Record: Owner’s Address: Date Rec’d Owner’s Phone: Fee: $50.00 Agent’s Name: Agent’s Address: Check No. Reg. No. Agent’s Phone: (Daytime) (Alternate) If owner does not reside in the tri-county area of Albany, NY an agent within this area must be designated. If the owner is a company/partnership/corporation an individual must be designated as the agent. Changes to any of the above information should be done by placing a line through the current information and filling in the correct information next to it. If you have any questions completing the information, please contact the Department of Buildings & Regulatory Compliance - (518) 434-5165. Signed: Title: Name: Company: Date: Please return this form along with the fee to the Department of Buildings & Regulatory Compliance - Make checks payable to "City of Albany". Thank you!