Republic of the Philippines

Department of the Interior and Local Government

BUREAU OF FIRE PROTECTION
Region 1
Naguilian Fire Station
(STATION)
Brgy. Ortiz, Naguilian, La Union
(Station Address)

Date: ________________

SUBJECT : Inspection of___________________________________________________________

FOR : CITY/MUNICIPAL FIRE MARSHAL

ATTN: CHIEF, FIRE SAFETY ENFORCEMENT SECTION

REFERENCE: INSPECTION ORDER NO.___________________ DATE ISSUED: __________________

DATE OF INSPECTION: __________________

NATURE OF INSPECTION CONDUCTED: [Check Appropriate Box]

[ ] Building Under Construction [ ] Periodic Inspection of Occupancy
[ ] Application for Occupancy Permit [ ] Verification Inspection of Compliance to NTCV
[ ] Application for Business Permit [ ] Verification Inspection of Complaint Received
[ ] Others (Specify) ________________________________________

SMALL/GENERAL BUSINESS ESTABLISHMENT CHECKLIST

I. GENERAL INFORMATION

Name of Building ___________________________________________________________________________________

Business Name _____________________________________________________________________________________
Address ___________________________________________________________________________________________
Nature of Business __________________________________________________________________________________
Name of Owner/Occupant_______________________________________________ Contact No.___________________
Name of Representative _________________________________________________Contact No. ___________________
No. of Storey ________________ Height of Bldg.___________ m Portion Occupied_____________________________
Area per Flr. _______________________________ sqm Total Flr. Area ____________________________sqm
Building Permit No.____________ Date Issued_________ Occupancy Permit No. ___________ Date Issued__________
Latest FSIC Issued Control No.____________________ Date Issued __________________ FC Fee _________________
Latest Notice to Correct Violations Cntrl No. _____________________________ Date Issued ______________________
Name of Fire Insurance Co/Co-Insurer_________________________ Policy No.__________ Date Issued ____________
Latest Mayors/Bus. Permit _____ Date Issued ________ Municipal License No. __________Date Issued ________
Latest Certificate of Electrical Inspection No. _____________________________Date Issued ______________________
Other Information ___________________________________________________________________________________

II. BUILDING CONSTRUCTION

Beams _________________________ Columns______________________ Flooring _____________________________

Exterior Walls ___________________Corridor Walls _________________ Room Partitions_______________________
Main Stair ______________________Windows______________________ Ceiling ______________________________
Main Door _____________________Trusses________________________ Roof ________________________________

III. SECTIONAL OCCUPANCY (Note: Indicate specific usage of each floor, section or rooms)
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
IV. MEANS OF EGRESS
a) No. of exits _____________________ Widths _____________________
Exits accessible? [ ] Yes [ ] No Termination of exits _________________________________________
Enclosure provided? [ ] Yes [ ] No Enclosure construction _______________________________________
Are fire doors provided? [ ] Yes [ ] No Fire door construction ________________________________________
b) No. of stair provided _____________ Width __________ Type ______________ Construction ___________________
Enclosure provided? [ ] Yes [ ] No Enclosure construction _______________________________________
Are fire doors provided? [ ] Yes [ ] No Fire door construction ________________________________________
Other details: ____________________________________________________________________________________
_______________________________________________________________________________________________

V. FIRE PROTECTION EQUIPMENT

a) Emergency lights provided? [ ] Yes [ ] No Illuminated exit signs provided? [ ] Yes [ ] No
b) No. of fire extinguisher ______________ Type ___________________ Capacity ______________________________
Accessible? [ ] Yes [ ] No Conspicuous location? [ ] Yes [ ] No

c) Is bldg equipped with fire alarm? [ ] Yes [ ] No Detectors? [ ] Yes [ ] No

Location of control panel ___________________ Functional? [ ] Yes [ ] No

VI. FLAMMABLES

a) Presence of hazardous materials? [ ] Yes [ ] No Properly stored and handled? [ ] Yes [ ] No

Kinds Container Volume Location

1. ___________________________ __________________ __________ ________________________________

2. ___________________________ __________________ __________ ________________________________

3. ___________________________ __________________ __________ ________________________________

Storage Permit for Flammables/Combustibles Covered by BFP Permit? _______________________________________

Clearance of Stocks From Ceiling _____________________________________________________________________
Minimum Ceiling Clearance: 1.0m for Flammable Liquids and 0.5m for Combustible Materials
No Smoking sign provided? [ ] Yes [ ] No Is smoking permitted? [ ] Yes [ ] No Where? ____________
Storage construction _______________________ Safety device for LPG tanks provided? [ ] Yes [ ] No
b) Oven/stove used _____________________________ Kind of fuel __________________________________________
Smoke hood? ________________ Spark arrester? ______________ Partition construction ______________________

VII. FINDINGS NOTED DURING INSPECTION

___________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
VIII. RECOMMENDATIONS
___________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

ACKNOWLEDGED BY:

____________________________________________ ____________________________________________
Signature Over Printed Name of Owner/Representative Fire Safety Inspector/s
Date & Time______________________

__________________________________________
Team Leader

RECOMMEND ISSUANCE OF FSIC/NTC/NTCV:

__________________________________________
CHIEF, FIRE SAFETY ENFORCEMENT SECTION

APPROVED/DISAPPROVED:

____________________________________
City Fire Marshal

Original (BFP copy)

Duplicate (BO or BPLO, as the case maybe)
Triplicate(Applicant/Owners Copy)