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Question	Answer
Form Name	Std 850 Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	form 850, ca std form 850, std 850 cdph form, inspection 850

12

Form Preview Example

STATE OF CALIFORNIA

FORESTRY AND FIRE PROTECTION

Clear

Print

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

NONAMBULATORY

BEDRIDDEN

TOTAL CAPACITY

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							2.			FIRE CLEARANCE DENIED
ADDRESS										A. EXITS
										B. CONSTRUCTION
										B. CONSTRUCTION
										C. FIRE ALARM
										C. FIRE ALARM
										D. SPRINKLERS
INSPECTOR'S NAME (Typed or Printed)			TELEPHONE NUMBER			CFIRS NUMBER	OCCUPANCY CLASS			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

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.

INSTRUCTIONS

STATE OF CALIFORNIA FORESTRY AND FIRE PROTECTION

FIRE SAFETY INSPECTION REQUEST

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

1. AGENCY CONTACT, 2. TELEPHONE NUMBER,

5. EVALUATOR.�Enter the name and telephone number of agency contact person.

3.PROGRAM. Licensing agency use.

4.REQUEST DATE. Enter date request was prepared.

6.REQUESTING AGENCY FACILITY NUMBER. This is the file number assigned by the licensing agency.

7.REQUEST CODE. Use the seven codes shown and insert the appropriate number in the box following "Request Code". If NAME CHANGE, please list previous name. Insert date of original request is other than an original.

8.AGENCY NAME AND ADDRESS. Enter the name and address of the licensing facility requesting the inspection.

9.AMBULATORY--NONAMBULATORY--BEDRIDDEN.

Capacity:	Insert in the appropriate section, the capacity
	of licensed ambulatory or nonambulatory oc-
	cupants covered by this request.
Previous	If request is for renewal or capacity change,
Capacity:	insert capacity of previous clearance.
Total	Show total licensed capacity. If the facility is
Capacity:	intended to house part ambulatory, nonambu-
	latory, and part bedridden, show the total of
	the three types of occupants.

10.FACILITY NAME. Insert the name of the facility as it will appear on the license. List identifying sub name if known (i.e., Hacienda Corp/Medina Lodge).

11.LICENSE CATEGORY. Insert the category of license being sought as it will appear on the license certificate.

12.ADDRESS. Insert street address and city only. A post office box is not acceptable as only location.

13.NUMBER OF BUILDINGS. Insert the total number of buildings to be used for housing of the occupants covered by the license.

14.RESTRAINT. Indicate if physical restraint (locked in a room or the building) is to be used in the housing of the occupants.

15.FACILITY CONTACT PERSON--TELEPHONE NUMBER. Indicate the name and telephone number of the responsible individual at the facility to be contacted by the fire authority.

16.HOURS. Indicate the number of hours the occupants are housed at the facility (less than 24 or 24+).

17. SPECIAL CONDITIONS. Indicate any conditions

unique to this request. As an example, if the inspection request is for one building in a multi-building facility.

FIRE AUTHORITY CONDUCTING THE INSPECTION--COMPLETE THE FOLLOWING:

18.FIRE AUTHORITY, NAME AND ADDRESS. Insert the name and address of the fire authority where the facility is located.

19.CLEARANCE/DENIAL CODE. Use the two codes: 1 for clearance granted, and 2 for clearance denied. If denied, also include the appropriate letter code. As an example, Denial based upon exiting would be coded 2A.

20.INSPECTOR'S NAME. Print the initial of the inspector's first name and full last name; insert the telephone number where the inspector may be contacted.

21.CFIRS I.D. NUMBER. Insert the fire department's number assigned by California Fire Incident Reporting System.

22.OCCUPANCY CLASSIFICATION. Use California Building Code occupancy classifications and insert the occupancy determined by the inspector.

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

24. INSPECTOR'S SIGNATURE. To be signed by the inspector conducting the inspection.

25.EXPLAIN DENIALOR SPECIAL CONDITIONS. If clearance code #2 is used, briefly explain reason. This space is also to be used to specify any additional limitations placed by the fire authority, such as the use of certain floors or sleeping rooms approved for nonambulatory clients.

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Step 1: The first step should be to choose the orange "Get Form Now" button.

Step 2: Now, you're on the form editing page. You may add information, edit present data, highlight specific words or phrases, put crosses or checks, insert images, sign the document, erase unrequired fields, etc.

The PDF document you plan to fill in will consist of the following segments:

ca std form 850 gaps to fill out

In the section FACILITY NAME, STREET ADDRESS Actual Location, CITY, LICENSE CATEGORY, NUMBER OF BUILDINGS, RESTRAINT, FACILITY CONTACT PERSONS NAME, FACILITY CONTACT PERSONS TELEPHONE, HOURS, SPECIAL CONDITIONS, FIRE AUTHORITY NAME AND ADDRESS, TO BE COMPLETED BY INSPECTING, INSPECTORS NAME Typed or Printed, TELEPHONE NUMBER, and CFIRS NUMBER enter the data that the application requests you to do.

ca std form 850 FACILITY NAME, STREET ADDRESS Actual Location, CITY, LICENSE CATEGORY, NUMBER OF BUILDINGS, RESTRAINT, FACILITY CONTACT PERSONS NAME, FACILITY CONTACT PERSONS TELEPHONE, HOURS, SPECIAL CONDITIONS, FIRE AUTHORITY NAME AND ADDRESS, TO BE COMPLETED BY INSPECTING, INSPECTORS NAME Typed or Printed, TELEPHONE NUMBER, and CFIRS NUMBER blanks to complete

Within the field talking about INSPECTION DATE, INSPECTORS SIGNATURE Typed or, EXPLAIN DENIAL OR LIST SPECIAL, F SPECIAL HAZARD, and G OTHER, make sure you type in some essential data.

ca std form 850 INSPECTION DATE, INSPECTORS SIGNATURE Typed or, EXPLAIN DENIAL OR LIST SPECIAL, F SPECIAL HAZARD, and G OTHER blanks to insert

Step 3: As soon as you click the Done button, the completed file is readily transferable to all of your gadgets. Alternatively, you may send it using mail.

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