Republic of the Philippines

Department of the Interior and Local Government

Bureau of Fire Protection
CARAGA REGIONAL OFFICE
Surigao del Norte Provincial Office
Santa Monica Fire Station
Brgy. T. Arlan, Sta. Monica, Surigao del Norte
Hotline No: 09985904312
Email Add: sdnstamonica25@gmail.com
____________________
(Name of Owner) DATE

(Name of Establishment)

(Address)

FOR : CITY/MUNICIPAL FIRE MARSHAL

ATTN : CHIEF, FIRE SAFETY ENFORCEMENT SECTION

REFERENCE: INSPECTION ORDER NO.______________________ DATE ISSUED ___________________

DATE OF INSPECTION:

NATURE OF INSPECT ION CONDUCTED: [ ] Check Appropriate Box

[ ] Building under Construction [ ] Periodic Inspection of Occupancy
[ ] Application for 0ccupancy Permit [ ] Verification Inspection of Compliance to NTCV
[ ] Application for Business Permit [ ] Verification Inspection of Complaint Received
[ ] Others (Specify) _________________________________________________________________________________

SINGLE AND TWO-FAMILY DWELLINGS CHECKLIST

I. GENERAL INFORMATION
Owner/Representative: _____________________________________________________________________________
Address: ________________________________________________________________________________________
Contact No. ______________________________________________________________________________________
Total Land Area: ______________________________ Total Floor Area: _________________________
Building Permit: _______________________________ Date Issued: ____________________________
Fire Code Fee ___________________ OR No. __________________ Date Issued ________________

II.BUILDING CONSTRUCTION
Beams _______________________
Exterior Walls__________________
Main Stair_____________________
Main Door_____________________
Columns____________________ Flooring ___________________________
Corridor Walls________________ Room Partitions______________________
Windows ____________________ Ceiling _____________________________
Trusses_______________________ Roof ____________________________

III. SECTIONAL OCCUPANCY (Note: Indicate specific usage of each floor, section or rooms)

IV. MEANS OF EGRESS

Readily accessible? [ ] Yes [ ] No Obstructed? [ ] Yes [ ] No
Travel distance within limits? [ ] Yes [ ] No Dead-ends within limits? [ ] Yes [ ] No
Adequate illumination [ ] Yes [ ] No Proper rating of illumination? [ ] Yes [ ] No
Panic hardware operational? [ ] Yes [ ] No Door swing in the direction of exit? [ ]Yes [ ] No
Doors open easily? [ ] Yes [ ] No Self-closure operational? [ ] Yes [ ] No
Bldg w/Mezzanine? [ ] Yes [ ] No Mezzanine with proper exits? [ ]Yes [ ] No

V. DEFECTS / DEFICIENCIES NOTED DURING INSPECTION (Attached pictures, sketch and others)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________.

BFP-QSF-FSED-021 Rev. 01 (07.05.19) Page 1 of 2

 Republic of the Philippines
Department of the Interior and Local Government
Bureau of Fire Protection

VI. RECOMMENDATIONS
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________.

ACKNOWLEDGED BY:

________________________________________ _____________________________________________
Signature Over Printed Name of Owner/ Fire Safety Inspector/s
Representative

Date & Time ____________________________ _____________________________________________

Team Leader

RECOMMEND ISSUANCE OF FSIC/NTC/NTCV:

______________________________________________
CHIEF, FIRE SAFETY ENFORCEMENT SECTION

APPROVED / DISAPPROVED:

_____________________________________________
CITY / MUNICIPAL FIRE MARSHAL

PAALALA: “MAHIGPIT NA IPINAGBABAWAL NG PAMUNUAN NG BUREAU OF FIRE PROTECTION SA MGA KAWANI NITO ANG
MAGBENTA O MAGREKOMENDA NG ANUMANG BRAND NG FIRE EXTINGUISHER”

“FIRE SAFETY IS OUR MAIN CONCERN”

DISTRIBUTION:
Original (Applicant/Owner’s Copy)
Duplicate (BO or BPLO, as the case may be)
Triplicate (BFP Copy)

BFP-QSF-FSED-021 Rev. 01 (07.05.19) Page 2 of 2