Fire Inspection Form - Town Of Selma

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TOWN OF SELMA
FIRE INSPECTION FORM
Name of buisness______________________________ Address________________________
Owner of Building_____________________ Owner of Buisness_________________________
Phone #____________ Emergency Contact_________________Other___________________
Function of Buisness_____________________________Occupancy Class________________
Square Footage____________ Building Hazards_____________________________________
____________________________________________________________________________
____________________________________________________________________________
Fire Inspection Checklist
General
Comments
Combustible Waste Accumlation Pass[ ] Fail [ ] N/A [ ]
_____________________
No Smoking Signs Posted
Pass[ ] Fail [ ] N/A [ ]
_____________________
Combustibles in Exits
Pass[ ] Fail [ ] N/A [ ]
_____________________
Evacuation Plans Psted
Pass[ ] Fail [ ] N/A [ ]
_____________________
6" Address Numbers Posted
Pass[ ] Fail [ ] N/A [ ]
_____________________
Electical
_____________________
Extension Cords Used Perm
Pass[ ] Fail [ ] N/A [ ]
_____________________
36" Clearance around Electric
Pass[ ] Fail [ ] N/A [ ]
_____________________
Open Wiring
Pass[ ] Fail [ ] N/A [ ]
_____________________
Exits, Lighting, & Doors
_____________________
Visible, Approved Exit Signs
Pass[ ] Fail [ ] N/A [ ]
_____________________
Egress Illuminated
Pass[ ] Fail [ ] N/A [ ]
_____________________
Exit Doors Open W/O Key
Pass[ ] Fail [ ] N/A [ ]
_____________________
Doors swing in direction of travel Pass[ ] Fail [ ] N/A [ ]
_____________________
Obstruction Free Exits
Pass[ ] Fail [ ] N/A [ ]
_____________________
Fire Extinguishers
_____________________
Fire Extinguishers provided
Pass[ ] Fail [ ] N/A [ ]
_____________________
Tested and Serviced Annually
Pass[ ] Fail [ ] N/A [ ]
_____________________
Within 75' of Travel Distance
Pass[ ] Fail [ ] N/A [ ]
_____________________
Conspicuous & unobstructed
Pass[ ] Fail [ ] N/A [ ]
_____________________
Mounted not over 5'
Pass[ ] Fail [ ] N/A [ ]
Fire Protection Systems
ALL FAILING ENTRIES
Fire Alarm Testing Document
Pass[ ] Fail [ ] N/A [ ]
MUST BE ADDRESSED
Sprinkler Clearance
Pass[ ] Fail [ ] N/A [ ]
WITHIN 30 DAYS OF THE
Hood Systems Cleaned
Pass[ ] Fail [ ] N/A [ ]
DATE OF THIS INSPECTION
Auto Extinguishing inspected
Pass[ ] Fail [ ] N/A [ ]
Class K Extinguisher
Pass[ ] Fail [ ] N/A [ ]
Decorative Material
Reinspection due on
Less than 20% of wall covered
Pass[ ] Fail [ ] N/A [ ]
_____________________
Fire Resistant Construction
Pass[ ] Fail [ ] N/A [ ]
Miscellanious
Proper Warning Signs
Pass[ ] Fail [ ] N/A [ ]
Inspection Fee ________
Emergency Shutoffs in place
Pass[ ] Fail [ ] N/A [ ]
Key Box Installed
Pass[ ] Fail [ ] N/A [ ]
Other
___________________________Pass[ ] Fail [ ] N/A [ ]
Pass[ ] Fail [ ] N/A [ ]
___________________________Pass[ ] Fail [ ] N/A [ ]
Pass[ ] Fail [ ] N/A [ ]
___________________________Pass[ ] Fail [ ] N/A [ ]
Pass[ ] Fail [ ] N/A [ ]
________________________
__________________________ Pass[ ] Fail [ ] N/A [ ]
Signed - Responsible Party
________________________
Date_________________
Signed - Fire Code Official

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