Std 850 Form PDF Details

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QuestionAnswer
Form NameStd 850 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesstd 850 fire inspection, inspection 850, fire clearance std 850 form, california 850

Form Preview Example

STATE OF CALIFORNIA FORESTRY AND FIRE PROTECTION

FIRE SAFETY INSPECTION REQUEST

STD. 850 (REV. 4-2000)

 

 

 

 

 

 

 

See instructions on reverse.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND

 

 

 

 

 

 

 

 

 

3.

CAPACITY CHANGE

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME AND

 

 

 

 

 

 

2.

FIRE CLEARANCE DENIED

ADDRESS

 

 

 

 

 

 

 

 

 

A. EXITS

 

 

 

 

 

 

 

 

 

 

B. CONSTRUCTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. FIRE ALARM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 SPECIALCONDITIONS

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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