Occupant/Business Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Form Completed by *

First Name

Last Name

Self-Inspection Date *

MM

DD

YYYY

I would like the Fire Marshal to follow-up with me to answer questions or to schedule an in-person inspection. *

Yes

No

1. Are all exits and fire escapes maintained in good, safe, usable condition? *

Yes

No

2. Are all exit lights in good working order? *

Yes

No

3. Are all exits free of obstruction? *

Yes

No

4. Are all employees familiar with emergency location exits? *

Option 1

Option 2

5. Is an evacuation plan posted at the main exit door inside of each room? *

Yes

No

6. Are all exits unlocked when the building is occupied? *

Yes

No

7. Are all fire doors and fire shutters in good operating condition and doors kept closed? *

Yes

No

8. Are fire drills conducted annually? *

Yes

No

1. Have all fire extinguishers been inspected within the last 12 months? *

Yes

No

2. Are all employees familiar with fire extinguisher locations and operation? *

Yes

No

1. If present, have sprinkler systems, standpipes and hose been inspected by a licensed contractor within the last 12 months? *

Yes

No

Not applicable

2. Is storage at least 18” below sprinkler heads? *

Yes

No

Not applicable

3. If present, have fire alarms and smoke detectors been inspected by a licensed service provider within the last 12 months? *

Yes

No

Not applicable

4. If present, have emergency notification alarms, call boxes and systems been inspected by a licensed service provider within the last 12 months? *

Yes

No

Not applicable

5. If present, have private fire hydrants been flow tested and serviced annually by a licensed service provider? *

Yes

No

Not applicable

1. Is all electrical wiring unexposed (no open electrical panels or junction boxes)? *

Yes

No

2. Are all electrical connections (splices) made in covered electrical junction box? *

Yes

No

3. Are there enough electrical outlets to prevent the use of extension cords in lieu of permanent wiring? *

Yes

No

4. Are electric control panels accessible and are circuits labeled? *

Yes

No

5. Are covers closed on electric panels? *

Yes

No

1. Are flammable and combustible liquids kept in approved containers? *

Yes

No

2. Are flammable and combustible liquids kept away from open flames, heating equipment or electrical control panels? *

Yes

No

1. Are papers, plastics and other combustibles kept in limited quantities so as to prevent a fire hazard? *

Yes

No

2. Is storage limited, accessible, orderly, and not within 24 inches of the ceiling? *

Yes

No

3. Are stairways, aisles and corridors free of storage? *

Yes

No

1. Is heating equipment in a safe and operable condition? *

Yes

No

2. Is storage kept away from water heaters, furnaces, and out of the boiler room? *

Yes

No

3. Is heating system adequate to prevent the use of portable heaters? *

Yes

No

1. Is your address visible from the road? *

Yes

No

2. Are all exits accessible and unobstructed? *

Yes

No

3. Are all exit lights operational? *

Yes

No

4. Are emergency exit lights operational? *

Yes

No