Questionnaire Name and Address of the client: Name and Address of the installation you need to protec Nature of the building: (use, nature of the manufactured or stored products) For a religious building: - Is there : © across... -QYes No © anornament .. OYes ONo © bells. -QYes ONo > Ityes, are they electric? > Are they protected by a lightning protector? + a-single-phase power supply cabinet. «a three-phase power supply cabinet... -Qyes ONo Oyes ONo -Oyes ONo QYes ONo - Is there an access on the roof: a trap door, a window: Dyes No (locate it on the diagram) - Will you erect a scaffolding on the religious building during the Work? .......0CI¥es — CNo For a building: -Is there: * roof antennas. OYes ONo + roof metal elements oa Brag ee eee tecmeereettosteeteesercmerterd| =) Cjeseee 1) © a gas rising column Oves No * in frontage electric cable Dyes ONo (locate them on the diagram) ~ Is it necessary to envisage a specific study about electric equipments protection against sunges ? staid -Qyes ONo - Nature of the ground for the lightning conductor earth rod - Nature of the possible floor covering:.. - Presence of others earth rod: (locate them on the diagram) electric (ground loop}... electric (rod)... telephone .. data processing -GYes — CINo Qyes No Qyes ONo -QYes ONo - Estimate for supply only Phemin dex Poses ~50500 Daal — FRANCE a indelec el avnsiton pans rue eontactandele.comDiagram Religious Building: A if Other Buildings: lH G t al +R OS we AE Tc Locate the place of the roof ornaments Locate the place of the chimneys, the antennas, ete. Dimensions in meters | Nature of the materials | Observations =| x]O}5]r| 0] 0) 0] > Cena asa AN indelec ataoitin pac eansg aie wel eontactandele.comFurther Information Necessary to ferrite me yeacis References: - Titles: - Pile: - Date: Structural coefficient: Roof | Metal Common Inflammable Structure Metal Common Inflammable Relative situation of the building: * The building is located in a place where there are others buildings, trees with the same height, or even higher. : 0 * The building is surrounded by smaller buildings oO * The building is isolated, there are no others . Oo + Isolated building at the top ofa hill, or on a headland Oo The building’s occupation: * Unoccupied .. oO + Normally occupied. o «Hard evacuation or risk of panic o The building’s contents: * Without value and inflammable........0.- 0 * Common value or normally inflammable. oO * Strong value or particularly inflammable... oO * Exceptional value, irreplaceable or very inflammable, explosive oO Consequences of a lightning struck: + No necessity of continuous service and no consequences on the environment... oO + Necessity ofa continuous service and no consequences on the environment Oo * Consequences on the environment.........0:.00 Oo Observations: 1, he Ps = Dat FERNCE Indelec |isuusuos smcnnsrouoss eontactandele.comFurther Information Necessary 't a : —the Evaluation of the Protection Level Brief sketch of the building: Tf possibie, join a photo or a postcard of the building Other information: I, Che dex Poses ~ 50500 Deval = FRANCE icasouoet Pac s38 S27 ou0908 PAlndelec Ema aR