|
| Please complete this worksheet for your business. If the business has multiple buildings, please fill out a work sheet for each building. |
|
| Submitter's Name:
|
 |
|
| Submitter's E-mail Address:
|
|
|
|
| Note that the submitter does not need to be the same as the contact person listed below, but we will use the submitter's name and email if we have follow-up questions or comments about your data. |
|
|
| We would like to follow-up annually via a phone call to determine if any substantial changes have been made |
|
|
| Basic Business Information |
|
| Business Name:
|
|
|
| Physical Address:
|
|
|
| City:
|
|
|
| State:
|
|
|
| Zip Code:
|
|
|
| Business Phone:
|
|
|
| Contact Name:
|
|
|
| Hours of Business:
|
|
|
|
| Emergency Contact Information |
|
| Emergency Contact #1:
|
|
|
| Phone Number:
|
|
|
| Emergency Contact #2:
|
|
|
| Phone Number 2:
|
|
|
|
| About Your Facility |
|
| If Residential, Number of Living Units:
|
|
|
| Number of Employees or Occupants:
|
|
|
| Number of Handicapped/ Special Needs:
|
|
|
| Length:
|
|
|
| Width:
|
|
|
| Square Footage:
|
|
|
| Does the building have a basement:
|
|
|
| If the building has a basement, does it have an outside entrance? If so, Where:
|
|
|
| Height (In Stories):
|
|
|
| Approximate Number of Occupants during normal Business Hours:
|
|
|
| Type of Alarm System(s) - Check ALL that Apply:
|
|
None
Burglar
Carbon Monoxide
Fire
Heat
Other
Smoke
|
| If OTHER, Please Specify:
|
|
|
| Location of Fire Alarm Panel:
|
|
|
| Location of Enunciator Panel:
|
|
|
| Alarm Power Supply:
|
|
|
| Manual Pull Stations:
|
|
|
| Alarm Connected to Phone Line for Reporting? :
|
|
|
| Alarm Company:
|
|
|
| Alarm Company Phone Number:
|
|
|
| Building Power:
|
|
|
| Location of Breaker Panel:
|
|
|
| Sprinkler System:
|
|
|
| Location of Sprinkler System Room:
|
|
|
| Stand Pipe System:
|
|
|
| Fire Department Connection (FDC):
|
|
|
| Location of FDC:
|
|
|
| Type of Gas:
|
|
|
| Location of Gas Shut off (If equipped):
|
|
|
| HVAC unit Location:
|
|
|
| A/C unit Location:
|
|
|
| Heating unit Location:
|
|
|
| Access to the roof:
|
|
|
| Location of roof access (If present):
|
|
|
| Elevator:
|
|
|
| Number of Elevators:
|
|
|
| Elevator(s) Location:
|
|
|
| Type of Elevator:
|
|
|
| Special Hazards (Explosives, Chemicals, Etc.):
|
|
|
|
| KNOX BOX |
|
| Do you have, or would you consider purchasing a secure Knox Box to provide keyed access for fire/EMS response? :
|
|
|
| Location of Knox Box (If present):
|
|
|
|
| Attachments |
|
| Please provide any photographs, diagrams, or information that could be used.:
|
|
|
