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November 2017 Page 1 of 1 City of Albany Department of Buildings & Regulatory Compliance 200 Henry Johnson Blvd. – Suite 1 Albany, NY 12210 Phone: (518) 434-5995 [EMAIL REDACTED] www.albanyny.gov WATER-BASED FIRE PROTECTION SYSTEM INSPECTION FORM The property owner (or designee) and an authorized water-based fire protection contractor shall fill out this form when a water-based fire protection system has been inspected and/or tested which is in the jurisdiction of the City of Albany. The contractor shall leave the form with the property owner and the property owner shall forward this form to the Department of Buildings & Regulatory Compliance with the appropriate fee required. A separate form must be submitted for each individual system. System Address: Type of Inspection or System Location, Id#, or Date(s) of Inspection: Property Contact Person: “This is to acknowledge that the above referenced water-based fire protection system located at the above referenced address in the City of Albany, NY, has been inspected and/or tested as per the annual requirements of NFPA 25 on the dates referenced above with the property owner”. Deficiencies Reported on I&T forms? If yes, were any Critical? “I hereby certify that I have read the instructions and examined this form and to the best of my knowledge the same to be true and correct”. Inspector (Print Signature of Inspection/Testing The property owner or representative shall return this form with appropriate fees required by the City of Albany. “I hereby certify that I have read the instructions and examined this form and to the best of my knowledge the same to be true and correct”, all deficiencies, if any, referenced above have been resolved (proof of such resolution may be required) and that the system referenced herein is in full compliance with all inspection, testing, & maintenance requirements of NFPA 25. Signature and Printed Name of Building Owner or Owner’s Representative who received copy of Inspection Form(s): Signature Printed Name