Self-fire Inspection Worksheet - City of Jerome, Idaho

This "Self-fire Inspection Worksheet" is a part of the paperwork released by the Idaho Department of Environmental Quality specifically for Idaho residents.

The latest fillable version of the document was released on January 1, 2015 and can be downloaded through the link below or found through the department's forms library.

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City of Jerome Fire Department
City of Jerome
City of Jerome
City of Jerome
110 W. Yakima Ave, Jerome, Idaho 83338, Phone: (208)324-2323 Fax: 324-4258
Self-Fire Inspection Worksheet
Version 01-2015
Business Name:
Business Phone #:
Address:
E-mail:
1. After-Hours Emergency Contact:
Contact Phone #:
2. After-Hours Emergency Contact:
Contact Phone #:
All businesses are encouraged to fill out and submit this inspection form. Fill in all the information on the form. Walk
through your occupancy to ensure the safety requirements on the checklist are fulfilled. If an item is in compliance, check
the “Yes” box. If an item is non-compliant, either remedy the problem before submitting this form or check the “No” box
and we will follow up in ensuring the hazard is corrected. If an item does not apply, check the “N/A” box. Any hazard not
addressed in the Self-Fire Inspection Form may be entered under “Additional Comments”
When completed, please drop off at Jerome City Fire Headquarters (110 W. Yakima Ave.). You can also fax it to 208-
324-4258 or scan/email to fireprevention@ci.jerome.id.us. Thank you for participating!
The list is intended to cover the most common items/hazards we encounter while performing fire inspections in low
hazard occupancies. It is not intended to be all comprehensive or replace specific code requirements not addressed on
the form. If you have specific code related question not addressed on this form, please call 208-324-2323 EXT-135.
Access & Premises
Yes
No
N/A
Are address numbers for the building clearly visible from the street?
Is the exterior fire department access unobstructed?
If the building has a Knox Box, are the building keys inside the box current?
Is combustible vegetation removed so as to not create a fire hazard?
Is there maintained a minimum 3' clearance around fire hydrants?
Egress (Exiting)
Yes
No
N/A
Are the exit ways and doors easily recognizable, unobstructed, and maintained functional?
If the main exit door is provided with key-locking hardware as allowed by code, is there a sign above the
door that states "THIS DOOR MUST REMAIN UNLOCKED WHEN BUILDING IS OCCUPIED" and are the
other exit doors openable from the inside w/o the use of a key or any special knowledge or effort?
Are the exits and exit enclosures free from the storage of combustible materials and obstructions?
Are doors with self-closing hinges maintained in the closed position (not blocked open)?
Electrical
Yes
No
N/A
Are all electrical outlets, switches and junction boxes properly covered with cover plates and is the
electrical system safe from any apparent shock and/or other electrical hazards?
Are circuit breakers/fuses labeled so as to identify the area protected?
Is the area maintained clear at least 30" in front of electrical panel(s)?
Are extension cords used only for temporary use?
Are extension cord(s) of heavy duty construction, maintained in good condition, and only used
as temporary wiring, or to service small portable appliances?
Are extension cord(s) grounded when serving grounded appliances?
Are extension cord(s) plugged directly into an approved receptacle, power tap or multi-plug adapter
and, except for approved multi-plug extension cord(s), serve only 1 portable appliance?
City of Jerome Fire Department
City of Jerome
City of Jerome
City of Jerome
110 W. Yakima Ave, Jerome, Idaho 83338, Phone: (208)324-2323 Fax: 324-4258
Self-Fire Inspection Worksheet
Version 01-2015
Business Name:
Business Phone #:
Address:
E-mail:
1. After-Hours Emergency Contact:
Contact Phone #:
2. After-Hours Emergency Contact:
Contact Phone #:
All businesses are encouraged to fill out and submit this inspection form. Fill in all the information on the form. Walk
through your occupancy to ensure the safety requirements on the checklist are fulfilled. If an item is in compliance, check
the “Yes” box. If an item is non-compliant, either remedy the problem before submitting this form or check the “No” box
and we will follow up in ensuring the hazard is corrected. If an item does not apply, check the “N/A” box. Any hazard not
addressed in the Self-Fire Inspection Form may be entered under “Additional Comments”
When completed, please drop off at Jerome City Fire Headquarters (110 W. Yakima Ave.). You can also fax it to 208-
324-4258 or scan/email to fireprevention@ci.jerome.id.us. Thank you for participating!
The list is intended to cover the most common items/hazards we encounter while performing fire inspections in low
hazard occupancies. It is not intended to be all comprehensive or replace specific code requirements not addressed on
the form. If you have specific code related question not addressed on this form, please call 208-324-2323 EXT-135.
Access & Premises
Yes
No
N/A
Are address numbers for the building clearly visible from the street?
Is the exterior fire department access unobstructed?
If the building has a Knox Box, are the building keys inside the box current?
Is combustible vegetation removed so as to not create a fire hazard?
Is there maintained a minimum 3' clearance around fire hydrants?
Egress (Exiting)
Yes
No
N/A
Are the exit ways and doors easily recognizable, unobstructed, and maintained functional?
If the main exit door is provided with key-locking hardware as allowed by code, is there a sign above the
door that states "THIS DOOR MUST REMAIN UNLOCKED WHEN BUILDING IS OCCUPIED" and are the
other exit doors openable from the inside w/o the use of a key or any special knowledge or effort?
Are the exits and exit enclosures free from the storage of combustible materials and obstructions?
Are doors with self-closing hinges maintained in the closed position (not blocked open)?
Electrical
Yes
No
N/A
Are all electrical outlets, switches and junction boxes properly covered with cover plates and is the
electrical system safe from any apparent shock and/or other electrical hazards?
Are circuit breakers/fuses labeled so as to identify the area protected?
Is the area maintained clear at least 30" in front of electrical panel(s)?
Are extension cords used only for temporary use?
Are extension cord(s) of heavy duty construction, maintained in good condition, and only used
as temporary wiring, or to service small portable appliances?
Are extension cord(s) grounded when serving grounded appliances?
Are extension cord(s) plugged directly into an approved receptacle, power tap or multi-plug adapter
and, except for approved multi-plug extension cord(s), serve only 1 portable appliance?
Is the ampacity of the extension cord(s) greater than the rated capacity of the portable appliance supplied
by the cord(s)?
If multiple items need to be plugged in, is a power tap utilized with a built-in circuit breaker and is the
power tap plugged directly into a permanently installed receptacle?
Emergency Lighting/Egress Illumination
Yes
No
N/A
If emergency lighting is provided, is it maintained in operable condition?
Is the means of egress illuminated when the building or structure is occupied?
Exit Signs
Yes
No
N/A
If exit signs are required, are they maintained illuminated or self-luminous?
Does the backup-battery work?
(push the test button, the exit sign should illuminate under battery power)
Fire Alarm System
Yes
No
N/A
If the building is equipped with a fire alarm system, has the required annual service of the fire alarm
system been performed by a qualified fire alarm company?
Date of last inspection or annual service: _____/_____/_____
Fire Safety & Evacuation Plans
Yes
No
N/A
If fire drills are required, are they conducted successfully at varying times and under varying conditions
and are records maintained on the premises?
If required, are Evacuation Plans posted?
If required, do you have Fire Safety Plans?
Fire Extinguishers
Yes
No
N/A
Is there unobstructed access to fire extinguisher(s) rated at a minimum 2A-10BC?
Is the travel distance from all portions of the building less than 75’ to a fire extinguisher?
Are all fire extinguishers visible and accessible (not blocked)?
Have the fire extinguisher(s) been serviced/tagged by a fire extinguisher company within the last 12
months? Date Serviced: _____/_____/_____
Are the fire extinguisher(s) properly mounted? (Proper locations-near exit doors where possible, not
exceeding maximum travel distance, properly mounted (maximum 5’ high if <40 lbs., maximum 3 ½’
high if >40 lbs. In all cases, minimum 4” above the ground).
Fire/Smoke Separations
Yes
No
N/A
Are the fire/smoke separations (smoke doors, fire doors, walls, etc.) maintained/working condition?
Fire Suppression Systems
Yes
No
N/A
Is the top of storage maintained a minimum 18” below head deflectors in fire sprinklered areas?
If the building is equipped with a fire sprinkler system, has the required annual service of the
fire sprinkler system been performed in the last year by a qualified sprinkler company?
Date of last inspection or annual service: _____/_____/_____
In commercial cooking applications, has the hood suppression system been serviced in the last
six months and is the hood cleaned at intervals to prevent the accumulation of grease?
Date of last inspection or annual service: _____/_____/_____
Heat Producing Appliances
Yes
No
N/A
If portable electric heaters are used, are they used safely? Also, are they plugged directly into wall outlets
and kept a minimum of 3' away from combustibles? (Open flame unvented heaters are prohibited for use
in a commercial occupancy).
Is the clearance between ignition sources, such as light fixtures, heaters, and flame producing devices,
and combustible storage maintained in an approved manner?
City of Jerome Fire Department
Self Fire Inspection Form Version 01-2015
Page 2 of 3
Housekeeping & Decorations
Yes
No
N/A
Is combustible rubbish that is stored in containers outside of vaults or rooms removed from the building a
minimum of once each working day?
Are oily rags or similar materials stored in metal, metal-lined or other approved containers equipped with
tight-fitting covers?
Is storage kept at least 2 feet below the ceiling?
Are all walls, floors, and ceilings maintained without holes?
Are combustible decorations flame retardant?
Mechanical Hazards
Yes
No
N/A
Is the venting for exhaust products of combustion intact for gas appliances (ie: water heaters, furnaces)?
Do natural gas appliances have individual gas shutoff valves?
Are safe clearances maintained between gas fired appliances (such as water heaters, furnaces, etc.)
and combustible materials?
Smoke Detectors
Yes
No
N/A
If smoke detection is required in common areas such as corridors or part of the fire alarm system, have
they been tested in the last year by a qualified service company?
Storage of Combustibles
Yes
No
N/A
Is the storage of combustible materials orderly?
Are combustible materials not stored beneath the building or structure?
Are the boiler rooms, mechanical rooms and electrical panel rooms maintained without the storage of
any combustible materials within?
Are rubbish containers over 5 1/3 cubic feet (40 gallons) provided with lids and made of noncombustible
construction?
Are dumpsters that are 1.5 cubic yards or more not stored inside the building and placed more than 5’
from combustible walls, openings or combustible roof eave lines?
Storage of Compressed Gas Cylinders
Yes
No
N/A
If you have compressed gas containers (such as co2, helium, etc.), are they chained to prevent falling?
Storage of Combustible and Flammable Liquids
Yes
No
N/A
Are flammable and combustible liquids stored in their original and/or approved container?
Are quantities in excess of 10 gallons of flammable and combustible liquids used for maintenance
purposes and the operation of equipment stored in liquid storage cabinets?
A “No” response to any of these questions indicates the presence of a possible fire code violation. Once all
hazards identified as having a “No” response are corrected, please sign, date, and return this form to the
fire department. Thank you for your cooperation.
Additional Comments:
Printed Name of Responsible Person
Signature of Responsible Person
Date
City of Jerome Fire Department
Self Fire Inspection Form Version 01-2015
Page 3 of 3

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