Fillable Fire Safety Inspection Request (Page 2 of 2) in pdf

STATE OF CALIFORNIA

FORESTRY AND FIRE PROTECTION

FIRE SAFETY INSPECTION REQUEST

INSTRUCTIONS

STD. 850 (REV. 4-2000) (REVERSE)

This form is designed for use with a window envelope

Licensing or Requesting Agencies--Complete the following 19 sections on this form

before submitting it to the fire authority having jurisdiction.

1. AGENCY CONTACT, 2. TELEPHONE NUMBER,

10. FACILITY NAME. Insert the name of the facility as it

5. EVALUATOR.

Enter the name and telephone number

will appear on the license. List identifying sub name if

of agency contact person.

known (i.e., Hacienda Corp/Medina Lodge).

3. PROGRAM.

Licensing agency use.

11. LICENSE CATEGORY. Insert the category of license

being sought as it will appear on the license certificate.

4. REQUEST DATE.

Enter date request was prepared.

12. ADDRESS. Insert street address and city only. A post

6. REQUESTING AGENCY FACILITY NUMBER.

This

office box is not acceptable as only location.

is the file number assigned by the licensing agency.

13. NUMBER OF BUILDINGS. Insert the total number of

7. REQUEST CODE.

Use the seven codes shown and insert

buildings to be used for housing of the occupants covered

the appropriate number in the box following "Request

by the license.

Code". If NAME CHANGE, please list previous name. Insert

date of original request is other than an original.

14. RESTRAINT. Indicate if physical restraint (locked in a

room or the building) is to be used in the housing of the

8. AGENCY NAME AND ADDRESS.

Enter the name and

occupants.

address of the licensing facility requesting the inspection.

15. FACILITY

CONTACT

PERSON--TELEPHONE

9. AMBULATORY--NONAMBULATORY--BEDRIDDEN.

NUMBER. Indicate the name and telephone number of

Capacity: Insert in the appropriate section, the capacity

the responsible individual at the facility to be contacted

of licensed ambulatory or nonambulatory oc-

by the fire authority.

cupants covered by this request.

16. HOURS. Indicate the number of hours the occupants are

If request is for renewal or capacity change,

housed at the facility (less than 24 or 24+).

Capacity:

insert capacity of previous clearance.

17. SPECIAL CONDITIONS.

Indicate any conditions

Total

Show total licensed capacity. If the facility is

unique to this request. As an example, if the inspection

Capacity: intended to house part ambulatory, nonambu-

request is for one building in a multi-building facility.

latory, and part bedridden, show the total of

the three types of occupants.

FIRE AUTHORITY CONDUCTING THE INSPECTION--COMPLETE THE FOLLOWING:

18. FIRE AUTHORITY, NAME AND ADDRESS. Insert the

22. OCCUPANCY CLASSIFICATION.

Use California

name and address of the fire authority where the facility is

Building Code occupancy classifications and insert the

located.

occupancy determined by the inspector.

Use the two codes:

19. CLEARANCE/DENIAL CODE.

23. INSPECTION DATE. Enter the actual date of the in-

for clearance granted, and 2 for clearance denied. If denied,

spection.

also include the appropriate letter code. As an example,

24. INSPECTOR'S SIGNATURE.

To be signed by the

Denial based upon exiting would be coded 2A.

inspector conducting the inspection.

20. INSPECTOR'S NAME. Print the initial of the inspector's

25. EXPLAIN DENIALOR SPECIAL CONDITIONS. If

first name and full last name; insert the telephone number

clearance code #2 is used, briefly explain reason. This

where the inspector may be contacted.

space is also to be used to specify any additional

limitations placed by the fire authority, such as the use of

21. CFIRS I.D. NUMBER. Insert the fire department's number

certain

floors

sleeping

rooms

approved

for

assigned by California Fire Incident Reporting System.

nonambulatory clients.

Fire Safety Inspection Request Page 2

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