Business Self-Inspection

Business Name (required)

Business Address Number (required)

Business Street Name (required)

Business Zip Code (required)

Is mailing address same as business address? (required)

Yes

No

If not what is the mailing address?

Business Contact Email (required)

Business Phone (required)

After Hours Emergency Contact Name (required)

Emergency Contact Phone Number (required)

Is the building address number posted with a contrasting background clearly visible from the street? (required)

Yes

No

Is the exterior of the building free from weeds, trash, debris or combustible storage? (required)

Yes

No

Are exit aisles and corridors a minimum of 36" wide and clear of obstructions? (required)

Yes

No

Are all exit doors unlocked, marked with exit signs and can easily be opened from the inside? (required)

Yes

No

Are walls intact without holes or open penetrations? (required)

Yes

No

Are ceiling tiles in place? (required)

Yes

No

N/A

Is a 30" wide and 36" deep unobstucted access space maintained in front of electrical panel? (required)

Yes

No

Are circuit breakers properly marked? (required)

Yes

No

Are unused circuit breaker spaces properly covered with blanks? (required)

Yes

No

Are cover plates in place for switches, receptacles and junction boxes? (required)

Yes

No

Are extension cords being used as permanent wiring? (required)

Yes

No

Are mechanical rooms, electrical rooms and areas under stairways clear of combustible storage? (required)

Yes

No

Is there a 24" clearance between storage and ceiling (non-sprinklered) or an 18" clearance between storage and sprinkler head (sprinklered)? (required)

Yes

No

Are combustibles stored at least three feet away from heat sources? (required)

Yes

No

Do fire extinguishers have a minimum rating of 2A/10BC? (required)

Yes

No

Are fire extinguisher locations visible and unobstructed? (required)

Yes

No

Have fire extinguishers been serviced and tagged by a qualified contractor within the past 12-months? (required)

Yes

No

Insert a photo of one fire extinguisher (include pressure gauge and service tag in photo) (required)

Service Company Name (required)

Service Date on Tag (required)

Kitchen suppression system (if present): Attach photo of the service tag found on the manual pull station.

Kitchen suppression system (if present): Service Company Name

Kitchen suppression system (if present): Service date on tag

Kitchen suppression system (if present): Service company name for hood and duct cleaning

Kitchen Suppression system (if present): Service date on tag for hood and duct cleaning

Print your Name (required)

Initial for Electronic Signature (required)