STD 850: California Fire Safety Inspection Request

Agency Contact, Telephone Number and Evaluator: enter the name and telephone number of agency contact person.

Request Date: enter date request was prepared.

Program: licensing agency use.

Requesting Agency Facility Number: this is the file number assigned by the licensing agency.

Request Code: use the seven codes shown and insert the appropriate number in the box following Request Code.

The seven codes shown are 1 Original, 2 Renewal, 3 Capacity Change, 4 Ownership Change, 5 Address Change, 6 Name Change and 7 Other.

If NAME CHANGE (number 6), please list previous name.

If the request is other than an original, insert the date of the original request.

Licensing Agency Name and Address: enter the name and address of the licensing facility requesting the inspection.

Capacity: insert in the appropriate section, the capacity of licensed ambulatory or nonambulatory occupants covered by this request.

Previous Capacity: if request is for renewal or capacity change, insert capacity of previous clearance.

Total Capacity: show total licensed capacity. If the facility is intended to house part ambulatory, nonambulatory, and part bedridden, show the total of the three types of occupants.

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).

License Category: insert the category of license being sought as it will appear on the license certificate.

Street Address (Actual Location) and City: insert street address and city only.

Common mistake: A post office box is not acceptable as only location.

Number of Buildings: insert the total number of buildings to be used for housing of the occupants covered by the license.

Restraint: indicate if physical restraint (locked in a room or the building) is to be used in the housing of the occupants.

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.

Hours: indicate the number of hours the occupants are housed at the facility (less than 24 or 24+).

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.

The part To Be Completed by Inspecting Authority is for the Fire Authority Conducting the Inspection to complete.

Fire Authority, Name and Address: insert the name and address of the fire authority where the facility is located.

Clearance/Denial Code: use the two codes: 1 for clearance granted, and 2 for clearance denied.

If denied, also include the appropriate letter code.

The codes shown are A Exits, B Construction, C Fire Alarm, D Sprinklers, E Housekeeping, F Special Hazard and G Other.

As an example, denial based upon exiting would be coded 2A.

Inspector's Name (Typed or Printed): print the initial of the inspector's first name and full last name; insert the telephone number where the inspector may be contacted.

CFIRS I.D. Number: insert the fire department's number assigned by California Fire Incident Reporting System.

Occupancy Classification: use California Building Code occupancy classifications and insert the occupancy determined by the inspector.

Inspection Date: enter the actual date of the inspection.

Inspector's Signature (Typed or Printed): to be signed by the inspector conducting the inspection.

Explain Denial or List 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.

On the reverse of STD. 850 (REV. 10/2019), the instructions say the form is designed for use with a window envelope and that Licensing or Requesting Agencies complete the following 19 sections on this form before submitting it to the fire authority having jurisdiction.