Republic of the Philippines

Department of the Interior and Local Government

BUREAU OF FIRE PROTECTION
Region 1
Naguilian Fire Station
(STATION)
Brgy. Ortiz, Naguilian, La Union
(Station Address)

Date: ________________

SUBJECT : Inspection of___________________________________________________________

FOR : CITY/MUNICIPAL FIRE MARSHAL

ATTN: CHIEF, FIRE SAFETY ENFORCEMENT SECTION

REFERENCE: INSPECTION ORDER NO.___________________ DATE ISSUED: __________________

DATE OF INSPECTION: __________________

NATURE OF INSPECTION CONDUCTED: [Check Appropriate Box]

[ ] Building Under Construction [ ] Periodic Inspection of Occupancy
[ ] Application for Occupancy Permit [ ] Verification Inspection of Compliance to NTCV
[ ] Application for Business Permit [ ] Verification Inspection of Complaint Received
[ ] Others (Specify) ________________________________________

CHECKLIST FOR SINGLE AND TWO-FAMILY DWELLINGS

I. GENERAL INFORMATION
Owner/Representative: ________________________________________________________________________
Address: ____________________________________________________________________________________
Contact No.: ________________________________ No. of Storey____________________________________
Total Land Area: _____________________________ Total Floor Area_________________________________
Building Permit No. __________________________________ Date issued ______________________________
Fire Code Fee ___________________ OR No. ________________________ Date issued ___________________

II. BUILDING CONSTRUCTION

Beams _________________________ Columns______________________ Flooring _____________________________

Exterior Walls ___________________Corridor Walls _________________ Room Partitions_______________________
Main Stair ______________________Windows_______________ ______Ceiling _________________________ ______
Main Door _____________________Trusses________________________ Roof ________________________________

III. SECTIONAL OCCUPANCY

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

IV. MEANS OF EGRESS

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

V. DEFECTS/DEFICIENCIES NOTED DURING INSPECTION (ATTACH PICTURES, SKETCHES AND

OTHERS)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
VI. RECOMMENDATIONS
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

ACKNOWLEDGED BY:

____________________________________________ ____________________________________________
Signature Over Printed Name of Owner/Representative Fire Safety Inspector/s
Date & Time______________________

__________________________________________
Team Leader

RECOMMEND ISSUANCE OF FSIC/NTC/NTCV:

__________________________________________
CHIEF, FIRE SAFETY ENFORCEMENT SECTION

APPROVED/DISAPPROVED:

Original (BFP copy) ____________________________________

Duplicate (BO or BPLO, as the case maybe) City Fire Marshal
Triplicate (Applicant/Owners Copy)