Required fields are marked with asterisks (*)

Commercial Business Self Fire Inspection Program

Dear Owner/Occupant:

You are eligible to perform your own self-fire inspection(s) which may decrease the interval an actual fire department inspection is conducted. You can perform these inspections as often as you desire. However, a reminder will be e-mailed to you on a yearly basis upon the renewal of a business license.

PERFORMING SELF-FIRE INSPECTIONS WILL PROMOTE A SAFER YEAR-ROUND ENVIRONMENT FOR YOUR BUSINESS AND THE PUBLIC. CONSIDER THE FOLLOWING ABOUT WORKPLACE FIRES:

There are approximately 75,000 fires annually that cost businesses over $2 billion
These fires kill more than 200 and injure more than 5,000 people each year
45% of businesses never reopen after a fire due to the high cost of recovery and repairs

The Draper City Fire Department is committed to the safety and security of our local businesses and their customers, guests, and employees. The purpose of this inspection is to ensure that the residents and visitors of Draper City have a safe place to do business.

You will find attached to this document a list of the forty four (44) most common fire code violations. Please answer each honestly. If the form is not properly or timely completed, you may be required to have a full fire department inspection and be subject to standard inspection fees.

Thank you for your participation!

If have any questions or concerns please feel free to contact:

Don Buckley
Fire Marshal
Draper City Fire Department
C-801-824-3714

Business Name

Phone Number- Business

Business License Number

Address

City

Zip Code

Name of Owner/Manager:

Phone Number- Primary

After-Hours Emergency Contact

Phone Number

Add Emergency Contact Remove

Access & Premises

Is your address on the outside of the building with a contrasting background and numbers at 5 inches in height?

Yes

N/A

Is the exterior fire department access unobstructed? (Can a fire truck get through your property)

Yes

N/A

Combustible vegetation (weeds, etc.) been removed so as not to create a fire hazard?

Yes

N/A

Is there a minimum of a 3 foot clearance around all fire hydrants?

Yes

N/A

Egress (Exiting)

Are the exitways and doors easily recognizable, unobstructed, and maintained and functional?

Yes

N/A

If the main exit door is provided with a key-locking hardware as allowed by code, is there a sign above the door that states “THIS DOOR MUST REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED” and are other exit doors openable from the inside without the use of a key or any special knowledge or effort?

Is the response above true for your establishment?

Yes

N/A

Are the exits and exit enclosures free from any storage and combustible materials?

Yes

N/A

Are doors with self-closing hinges maintained in the closed position (NOT BLOCKED OPEN)?

Yes

N/A

Exit Signs

Does the backup-battery work? (push the test button, the exit sign should illuminate under battery power)

Yes

N/A

If exit signs are required, are maintained illuminated or self-luminous?

Yes

N/A

Emergency Lighting/Egress Illumination

Is the means of egress illuminated when the building or structure is occupied?

Yes

N/A

If emergency lighting is provided, is it maintained in an operable condition?

Yes

N/A

Fire Extinguishers

Is there a clear 3 foot access around all fire extinguishers rated at a minimum of a 2A10BC?

Yes

N/A

Is the travel distance from all portions of the building less than 75 feet to a fire extinguisher?

Yes

N/A

Are all fire extinguishers visible and accessible (not blocked)?

Yes

N/A

Have all of the fire extinguishers been serviced and tagged by a certified fire extinguisher company within the last 12 months?

Yes

N/A

Are the fire extinguishers properly mounted?

Yes

N/A

Fire Suppression System

If the building is equipped with a fire sprinkler system, has the required annual service of the fire sprinkler system been performed in the last year by a qualified fire sprinkler contractor?

Yes

N/A

Please list the Fire Sprinkler Company name:

If you have a commercial cooking operation has the kitchen hood been serviced in the last six month by a certified technician? And has the hood been cleaned by a certified hood cleaning company to prevent the accumulation of grease?

Yes

N/A

Please provide the hood suppression company’s name:

Please provide the hood cleaning company’s name:

Fire Alarm System

If the building is equipped with a fire alarm system, has the required annual inspection and service of the fire alarm system been performed by a certified fire alarm company?

Yes

N/A

Please provide the name of the fire alarm company:

Fire/Smoke Separations

Are the fire/smoke separations (smoke doors, fire doors, walls etc.) maintained/working condition?

Yes

N/A

Heat Producing Appliances

If portable electric heaters are used, are they used safely? Also are they plugged directly into wall outlets and kept a minimum of 3 feet away from any combustibles? (Open flame unvented heaters are prohibited for use in a commercial occupancy).

Yes

N/A

Is the clearance between ignition sources, such as light fixtures, heaters, and flame producing devices, and combustible storage maintained in an approved manner? 18 – 24 inches

Yes

N/A

Mechanical Hazards

Is the venting for exhaust products of combustion intact for gas appliances (i.e.: water heaters, furnaces)?

Yes

N/A

Are safe clearances maintained between gas fired appliances (such as water heaters, furnaces, etc. ) and combustible materials? Minimum of 3 feet.

Yes

N/A

Is your heating/air conditioning unit cleaned and/or new filters installed on a regular basis?

Yes

N/A

Electrical

Are all electrical outlets, switches and junction boxes properly covered with cover plates and is the electrical system safe from any apparent shock and/or other electrical hazards?

Yes

N/A

Are all circuit breakers/fuses labeled so as to identify the area protected?

Yes

N/A

Are all circuit breakers/fuses clear of any tape, string or wire that would affect their operation?

Yes

N/A

Are all empty circuit breakers/fuses covered with a listed and approved blank cover?

Yes

N/A

Is the area in front of the electrical panel clear for a minimum of 3 feet?

Yes

N/A

Are extension cord(s) used only for temporary use only?

Yes

N/A

Are extension cord(s) of heavy duty construction, maintained in good condition, and only used as temporary wiring, or to service small portable appliances?

Yes

N/A

Are extension cord(s) plugged directly into an approved receptacle, power tap or multi plug adapter and, except for approved multi-plug extension cord(s), serve only 1 portable appliance?

Yes

N/A

Is the ampacity rating of the extension cord(s) greater than the rated capacity of the portable appliance supplied by the cord(s)?

Yes

N/A

If multiple items need to be plugged in, is a power tap utilized with a built-in circuit breaker and is the power tap plugged directly into a permanently installed receptacle?

Yes

N/A

Housekeeping and Decorations

Is combustible rubbish that is stored in containers outside of vaults or rooms removed from the building a minimum of once each working day?

Yes

N/A

once each working day? Are oily rags or similar materials stored in metal, metal-lined or other approved containers equipped with tight fitting covers?

Yes

N/A

Are combustible decorations flame retardant?

Yes

N/A

Are gas shut off valves clear of weeds, trash, storage etc., and are they visible and accessible?

Yes

N/A

Storage of Combustibles

Is the storage of combustible materials orderly?

Yes

N/A

Is the top of storage maintained a minimum of 24 inches or more below the ceiling in non-sprinklered area of buildings or a minimum of 18 inches below the sprinkler head deflectors in fire sprinklered areas of buildings?

Yes

N/A

Are combustible materials not stored beneath the building or structure?

Yes

N/A

Are rubbish containers over 5 1/3 cubic feet (40 gallons) provided with lids and made of noncombustible construction?

Yes

N/A

Are dumpsters that are 1.5 cubic yards or more not stored inside the building and placed more than 5 feet from combustible walls, openings or combustible roof eave lines?

Yes

N/A

Is there any combustible storage under any stairways in a non-sprinklered area of the building?

Yes

N/A

Storage of Compressed Gas Cylinders

If you have compressed gas containers (such as co2, helium, etc.), are they chained to prevent falling?

Yes

N/A

Storage of Combustible and Flammable Liquids

Are quantities in excess of 10 gallons of flammable and combustible liquids used for maintenance purposes and the operation of equipment stored in flammable or combustible liquid storage cabinets?

Yes

N/A

A “No” response to any of these questions indicates the presence of a fire code violation. Once all hazards identified as having a “No” response are corrected, please sign, date and return this form to us.

The purpose of this inspection is to ensure that the residents and visitors of Draper City have a safe place to do business. By the order of the Draper City Fire Marshal any person who willfully states as true, any material herein which he/she knows to be false, may be guilty of perjury.

Signature:

Full Name of Signee

Date:

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