Fire Safety Inspection Request
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STATE OF CALIFORNIA
FORESTRY AND FIRE PROTECTION
FIRE SAFETY INSPECTION REQUEST
See instructions on reverse.
STD. 850 (REV. 4-2000)
AGENCY CONTACT'S NAME
TELEPHONE NUMBER
REQUEST DATE
PROGRAM
EVALUATOR'S NAME
REQUESTING AGENCY FACILITY NUMBER
REQUEST CODE
CODES
1. ORIGINAL
A. FIRE CLEARANCE
LICENSING
2. RENEWAL
B. LIFE SAFETY
AGENCY
3. CAPACITY CHANGE
NAME AND
ADDRESS
4. OWNERSHIP CHANGE
5. ADDRESS CHANGE
6. NAME CHANGE
7. OTHER
AMBULATORY
BEDRIDDEN
TOTAL CAPACITY
NONAMBULATORY
CAPACITY
PREVIOUS CAPACITY
CAPACITY
PREVIOUS CAPACITY
CAPACITY
PREVIOUS CAPACITY
FACILITY NAME
LICENSE CATEGORY
STREET ADDRESS (Actual Location)
NUMBER OF BUILDINGS
CITY
RESTRAINT
FACILITY CONTACT PERSON'S NAME
FACILITY CONTACT PERSON'S TELEPHONE NUMBER
HOURS
SPECIAL CONDITIONS
TO BE COMPLETED BY INSPECTING AUTHORITY
CLEARANCE /DENIAL CODE
CODES
FIRE
1. FIRE CLEARANCE GRANTED
AUTHORITY
2. FIRE CLEARANCE DENIED
NAME AND
ADDRESS
A. EXITS
B. CONSTRUCTION
C. FIRE ALARM
D. SPRINKLERS
INSPECTOR'S NAME (Typed or Printed)
TELEPHONE NUMBER
CFIRS NUMBER
OCCUPANCY CLASS
E. HOUSEKEEPING
F. SPECIAL HAZARD
INSPECTION DATE
INSPECTOR'S SIGNATURE (Typed or Printed)
G. OTHER
EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS
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Parent category: Business