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Self Inspection Form

Business Name

Business Address

Suite

City, State, Zip

Business Phone Number

Email Address

Exterior Inspection

YES NO N/A
The address is placed in a position on the building that is obviously visible from the street
YES NO N/A
Does your business use the Knox Box entry system, if yes are your keys up to date

Exits

YES NO N/A
Exits are clear of obstructions, debris and clutter
YES NO N/A
Exits are marked with proper signage and illuminated

Fire Extinguishers

YES NO N/A
One 2A10BC (5 lb.) fire extinguisher for every 3,000 square feet or 75 feet of travel
YES NO N/A
Extinguishers are serviced, inspected and tagged annually by a qualified technician
YES NO N/A
Fire extinguishers are visible, in an accessible location (top no more than 5 feet above the floor, bottom no less than 4 inches from floor)
YES NO N/A
Fire extinguishers are installed in a cabinet or on hangers or brackets supplied by manufacturer

House Keeping

YES NO N/A
Boiler, mechanical and electrical rooms are not used as storage (unless specifically designed)
YES NO N/A
All compressed gas cylinders are secured
YES NO N/A
Combustible materials creating a fire hazard are not present

Electrical

YES NO N/A
Extension cords are not used as permanent wiring
YES NO N/A
Approved power taps (surge protectors) are used for multi plug applications
YES NO N/A
Power taps and extension cords are plugged directly into permanent outlets (Daisy chaining is not permitted)
YES NO N/A
Portable electric heaters are plugged directly into a permanent outlet
YES NO N/A
Electrical splices are enclosed in an approved electrical box
YES NO N/A
Electrical boxes are equipped with intact approved covers
YES NO N/A
Clear space is maintained in front of service panels of at least 30 inches in width by 36 inches in depth by 72 inches in height

A "No" response to any of these questions indicates the presence of a fire code safety hazard. Once all hazards identified as having a "No" response are explained with an estimated date of correction please sign, date and return this form to us.

Corrections that need to be addressed and estimated completion date

Comments

Name of person submitting form Phone Number

Position Title

By checking the box below, I agree to sign the document electronically. I agree that an electronic signature is as legally binding as if I had signed on paper. I have filled out this form accurately and honestly to the best of my knowledge. I assume all liability for any false information provided.

Electronic Signature

Date


For questions regarding this form or your self-inspection please call Alice at 509-933-7234.


Contact Information

Business Hours: Monday-Friday 8:00am-5:00pm

Administrative Office & Mailing Address: 400 E. Mountain View Ave, Ellensburg WA 98926

Phone: 509.933.7231

Request for Public Records

VOLUNTEER OPPORTUNITIES

To volunteer with KVFR give us a call at: (509) 933-7231