Self Inspection Survey Form Name of Person Completing Inspection* Job Title* Occupancy Name* Occupancy Street Address* Address (Continued)* City* State* Zip* Your Business Website Business Email Address* Occupancy Phone #* Business Owners Name* Business Owner's Phone #* Emergency Contact Person 1* Emergency Contact Person 1 Phone number* Emergency Contact Person 2 Emergency Contact Person 2 Phone number Address numbers for this occupancy are clearly visible and face the street so my building can be found in an emergency.* Yes No When the building is occupied, all exit door are unlocked from the inside so people can get out in an emergency.* Yes No The emergency back up lights and exit lights are working?* Yes No All exits are clearly marked and well lighted so people can find their way out.* Yes No Are any multi-plug adaptors such as cube adaptors, un-fused plug strips or any other device that does not comply with the National Electrical Code being used?* Yes No All aisles, hallways, doors, stairs, landings, fire escapes and other walkways are free of any obstructions that might block a quick escape.* Yes No The emergency telephone number 9-1-1 is clearly posted on or near all telephones.* Yes No All fire extinguishers have been serviced by a properly trained service technician. (Owner/Occupant performs monthly inspections to ensure proper pressure and check for damage).* Yes No Are all of your electrical appliances connected to an outlet or power strip with circuit breaker protection?* Yes No All employees and customer who smoke are encouraged to put their ashes in metal containers.* Yes No All furnace, electrical and storage rooms should be free of waste paper, rubbish and other combustibles.* Yes No Thank you Thank you for your submission. Your application for our Business Self Inspect is under review. We will notify you soon to advise if your application is approved. Please keep a copy for your records. Thank you for your cooperation. For further questions please contact us at 636-447-6655. Signature*CAPTCHAComments
