You must have JavaScript enabled to use this form. OCCUPANT/BUSINESS AND INSPECTION INFORMATION Occupant/Business Name Occupant/Business Address Occupant/Business Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Contact Email Address EXITS Are all exits and fire escapes maintained in good, safe, usable condition? Yes No Are all exit lights illuminated at all times? Yes No Do all exit doors open easily with no obstructions? Yes No Is the access to all exit doors unobstructed? Yes No Are all employees familiar with emergency exit locations? Yes No Are all exit doors unlocked when the building is occupied? Yes No FIRE EXTINGUISHERS Have all fire extinguishers been inspected by a certified provider within the last 12 months? Yes No Are all employees familiar with fire extinguisher locations and operation? Yes No FIRE PROTECTION AND EQUIPMENT If present, have sprinkler systems and standpipes been inspected by a licensed contractor within the last 12 months? Yes No Is storage at least 18” below sprinkler heads or at least 24” below the ceiling in non-sprinkled areas? Yes No If present, have fire alarms been inspected and tagged by a licensed service provider within the last 12 months? Yes No ELECTRICAL WIRING Is all electrical wiring unexposed (no open electrical panels or junction boxes)? Yes No Are all electrical connections (splices) made in covered electrical junction box? Yes No Are there enough electrical outlets to prevent the use of extension cords in lieu of permanent wiring? Extension cords and multi-plug adapters are prohibited. Yes No Are breaker panels accessible and are circuits labeled? Yes No Are covers closed on electric panels? Yes No STORAGE Are papers, plastics and other combustibles kept in limited quantities so as to prevent a fire hazard? Yes No Are stairways, aisles and corridors free of storage? Yes No HEATING EQUIPMENT Is heating equipment in a safe and operable condition? Yes No Is storage kept at least 36” away from water heaters and furnaces, and out of the boiler room? Yes No Additional comments, questions, suggestions to improve the fire division's service delivery: EMERGENCY (AND/OR AFTER HOURS) CONTACT INFORMATION Please provide three emergency contacts, if possible. Name First Last Phone Type - Type -HomeOfficeCell Phone Ext: Name First Last Phone Type - Type -HomeOfficeCell Phone Ext: Name First Last Phone Type - Type -HomeOfficeCell Phone Ext: Submit
