Directions

• Please fill out this form as completely as possible.
• Walk through the occupancy premises with the survey you received in the mail.
• Answer all the questions listed below. For those that do not apply to your occupancy or tenant space, write N/A (not applicable).
• Enter the name of person completing inspection, date and submit this form when the self inspection has been completed and corrections have been made.

Business Information

Business Name*

Site Address*

Mailing Address*

Occupancy Phone*

Occupancy Fax

Manager Information

Business Manager's Name*

After Hours Phone*

Email Address

Emergency Contact Information

1st Emergency Contact Name*

After Hours Phone*

2nd Emergency Contact Name

After Hours Phone

Inspection Questions

Address numbers for this occupancy are clearly visible and face the street so my building can be found in an emergency.*

Yes No

N/A

When the building is occupied, all exit doors are unlocked from the inside so people can get out in an emergency.*

Yes No

N/A

All exits are clearly marked and well-lighted so people can find their way out.*

Yes No

N/A

All aisles, hallways, doors, stairs, landings, fire escapes, and other walkways are free of any obstructions that might block quick escape.*

Yes No

N/A

All fire extinguishers have been serviced by properly trained service technicians. Perform monthly inspections to ensure proper pressure and check for damage.*

Yes No

N/A

All electrical cords, fuse boxes, circuit panels, and equipment have been checked to see they are in good condition and are not overloaded.*

Yes No

N/A

All employees and customers who smoke are encouraged to put their ashes in metal containers.*

Yes No

N/A

All furnace, electrical, and storage rooms should be free of waste paper, rubbish, and other combustibles.*

Yes No

N/A

Inspection Completed By:

Today's Date:

Thank You
If you answered “Yes” in all applicable categories, congratulations. You and your employees have a good approach to fire safety.

If you answered “No” to any questions and need information on how to correct the problem or if you would like more information on how improve fire-safety, please call the Fire Marshal's Office (253) 946-7248.