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Business Self-Inspection Program

2. Self-Inspection Report

4. Is this an "In Home" business?

   If so, check the box and fill out the next section.

   1. Yes
6. Business Contact and Address Information

8. Occupant/Business Name

10. Type of Business

11. Phone

13. Business Address

14. Fax

16. Owner/Manager

17. Owner/Manager Phone

19. Owner/Manager Address

21. Other Responsible

22. Other Responsible Phone

24. Other Responsible Address

26. Self-Inspection Checklist

28. Note
    If any of the following items do not apply to your business, N/A is an acceptable answer.

    If any of the following items do not apply to your business, N/A is an acceptable answer.

30. 1. Are address or suite numbers for the building clearly visible from the street?

    1. Yes

    1. No

    1. N/A

32. 2. Are exit ways and doors easily recognizable, unobstructed and unlocked during business hours?

    1. Yes

    1. No

    1. N/A

34. 3. Are circuit breakers/fuses labeled so as to identify the area protected and is there 36" of clearance around panel box?

    1. Yes

    1. No

    1. N/A

36. 4. Are all electrical outlets, switches and junction boxes properly covered?

    1. Yes

    1. No

    1. N/A

38. 5. Are electrical / mechanical rooms free of combustible storage?

    1. Yes

    1. No

    1. N/A

40. 6. If electrical outlet multi-plug adapters are used, are they provided with built-in circuit breaker protection?

    1. Yes

    1. No

    1. N/A

42. 7. If there are lighted exit signs, are all the bulbs illuminated when the building is occupied?

    1. Yes

    1. No

    1. N/A

44. 8. Are doors with self-closing hinges maintained in the closed position (not blocked open)?

    1. Yes

    1. No

    1. N/A

46. 9. Is there at least 18" of clearance below the bottom of the sprinkler heads?

    1. Yes

    1. No

    1. N/A

48. 10. Do you have access to a fire extinguisher rated 2A-10BC or greater; is it visible and accessible (not blocked); has it been serviced and tagged by a fire extinguisher company within the last 12 months and is it mounted on a wall no higher than 5'? **

    1. Yes

    1. No

    1. N/A

50. "NO" responses to any of these questions indicates the presence of a fire code violation. Once all hazards identified with a "NO" answer have been corrected, please sign, date and return this form to us.

52. ** Note
    If you are in a Building Complex that provides fire extinguishers in the hallways, they should be maintained by a Building Owner or Manager. In addition, any lighted exit signs or emergency lighting systems should be maintained in working condition. These common areas will be inspected by our staff, but if you note a deficiency, please bring it to our attention. Our phone number is (541) 450-6200.

    If you are in a Building Complex that provides fire extinguishers in the hallways, they should be maintained by a Building Owner or Manager. In addition, any lighted exit signs or emergency lighting systems should be maintained in working condition. These common areas will be inspected by our staff, but if you note a deficiency, please bring it to our attention. Our phone number is (541) 450-6200.

54. Confirmation

56. Name of Responsible Person

58. Signature of Responsible Person

    Entering the name, date and time, serves as the signature for this online form.

59. Date and Time of Signature
    Date and Time of Signature

    Date and Time of Signature

Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit

* indicates a required field