Self-Inspection Worksheet

Please complete the top of this form regarding your business name and mailing address. If your mailing address is different than your business address, please note it below.
Walk through your business space(s) answer all questions that apply to your area (s) below. If an item does not apply, please mark NA in that column.
You may request assistance with your inspection by checking the line on the bottom of page two of this form.

Business Information

Business Name

Business Address

Business Address 2

Business City/Town

Business ZIP/Postal Code

Different mailing address than the physical address

Yes

Business Mailing Address

Business Mailing Address 2

Business Mailing City/Town

Business Mailing ZIP/Postal Code

Inspection Information

1. Is your address or unit number visible from the street, and do the numbers contrast with their background?

Have you now corrected this?

2. Are all exterior trash containers (dumpsters) located at least five feet away from the building, and are the lids kept closed?

Have you now corrected this?

3. Is the exterior of your building kept free of weeds, trash, or debris?

Have you now corrected this?

4. Are exit doors and hallways clear of all obstructions, including storage?

Have you now corrected this?

5. If illuminated EXIT signs are provided, are they in working condition? There is a battery test button on the exterior of the exit sign.

Have you now corrected this?

6. Are circuit breakers panels unobstructed with a minimum of 36” of clearance provided?

Have you now corrected this?

7. Are all cover plates in place on electrical outlets and switches within your space(s)?

Have you now corrected this?

8. Are extension cords used?

Have you removed and replaced them with an electrical outlet to support the electrical device? Extension cords are for temporary use only.

9. Are multi-plug adapters in use?

Please remove and replace them with an approved “breaker” multi-plug unit with a fuse.

10. Are mechanical, boiler, and furnace rooms in your space(s) free of any combustible storage and materials?

Have you now corrected this?

11. Storage shall be located no less 18” below sprinkler head (if any) or 24” below the ceiling. Does your room meet this provision?

Have you now corrected this?

12. Have fire extinguishers been inspected and serviced within the last year by a licensed company? Is the extinguisher(s) marked so by a proper tag?

Have you now corrected this?

13. Is the fire extinguisher mounted on the wall so that it is visible and accessible for use? (Not blocked by storage).

Have you now corrected this?

14. If you are required to maintain your fire alarm system, has it been inspected annually?

Have you corrected this?

15. If you are required to maintain your fire sprinkler system, has it been inspected annually?

Have you now corrected this?

16. If you are required to maintain your kitchen hood suppression system, has it been inspected bi-annually?

Have you now corrected this?

How long did it take you to perform this inspection?

Declaration

By typing your name below, you are declaring that the preceding is true and correct.

First

Last

Contact Phone Number

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