Std 850 Form – Fill Out and Use This PDF

CITY

RESTRAINT

FACILITY CONTACT PERSON'S NAME

FACILITY CONTACT PERSON'S TELEPHONE NUMBER

HOURS

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.

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.

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.