Republic of the Philippines

Department of the Interior and Local Government

Bureau of Fire Protection
TALAINGOD FIRE STATION – DAVAO DEL NORTE PROVINCE
Purok 4B, Sto.Nino, Talaingod, Davao del Norte
09617826626
Email:talaingodfirestation@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) __________________________________________________________________________________

PLACES OF ASSEMBLY OCCUPANCY CHECKLIST

I. GENERAL INFORMATION
Name of Building____________________________________________________________________________________
Business Name_____________________________________________________________________________________
Address___________________________________________________________________________________________
Nature of Business__________________________________________________________________________________
Name of Owner/Occupant____________________________________ Contact No.__________________________
Name of Representative______________________________________ Contact No. __________________________
No. of Storey__________ Height of B1dg. __________(m) Portion Occupied_________________________________
Area per flr __________________________sqm Total Flr. Area ___________________________________sqm
Building Permit No ___________ Date Issue_______ Occupancy Permit No.______ Date Issued ______________
Latest FSIC Issued Control No. _______________ Date Issued_______________ FC Fee________________________
Certificate of Fire Drill __________________Date Issued_________________ FC Fee________________________
Latest Notice to Correct Violations Control No. ____________________________ Date Issued____________________
Name of Fire Insurance Co/Co-Insurer________________ Policy No.___________ Date Issued________________
Latest Mayor's/Bus. Permit _________ Date Issued______ Municipal License No._____ Date Issued_____________
Latest Certificate of Electrical Inspection No. __________________ Date Issued_____________________________
Other Information___________________________________________________________________________________

II.BUILDING CONSTRUCTION
Beams ________________________ Columns_____________________ Flooring _______________________________
Exterior Walls__________________ Corridor Walls________________Room Partitions __________________________
Main Stair_____________________ Windows_____________________Ceiling__________________________________
Main Door____________________ Trusses_______________________Roof __________________________________

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

IV. CLASSIFICATION
Occupant Load:______________________________ Egress capacity________________________________________
(requirement: 0.65 sq.m. per person for concentrated use without fixed seat; 1.4 sq.m. per person for less concentrated
use and 0.28 sq.m. per person for standing room or waiting space)
Any renovations [ ] Yes [ ] No Windowless: [ ] Yes [ ] No

V. EXIT DETAILS
Capacity of Horizontal Exit (Corridor Hallway):______ ( Requirement:100 persons per unit of exit width per min)
Capacity of Exit Stair: ________________________(Requirement:75 persons per unit of exit width per min)
No. of Exits_______________________________________________ Remote [ ] Yes [ ] No
Minimum Requirement: No. of Exits: Class A-at least 4 separate; Class B –at least 3; Class C-at least 2
Location of Exit_____________________________________________________________________________________
Maximum Travel Distance Requirement from Farthest Room: 46 m without AFSS & 61m with AFSS

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

Any Enclosure Provided [ ] Yes[ ] No Min of 2-hr fire rating- 4-storey or more, Min of 1 hr, fire rung- less than 4-
MEANS OF EGRESS storey
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
Corridors & aisles of sufficient size [ ] Yes [ ] No
A. VERTICAL EXITS
1.Main stairway: Width___________________________ Construction ____________________________________
Are there railings provided [ ] Yes [ ] No Made of ________________________________________________________
Any enclosure provided [ ] Yes [ ] No Enclosure construction________ Any opening [ ] Yes [ ] No
Fire door construction_________________________ Door equipped w/ Self-closing device [ ] Yes [ ] No
Door proper rating: [ ] Yes [ ] No Door provided w/ vision panel: [ ] Yes [ ] No If Yes, made of ___________________
Door swing in the direction of exit travel (when required) [ ] Yes [ ] No
Stairways Pressurized [ ] Yes [ ] No [ ] N/A If pressurized, what type or method ________________________
Date Last Tested ___________________________________________________________________________________
2. Secondary Stair/Fire Escape: Number______________________________ Width___________________________
Construction__________________ Are there railings provided [ ] Yes [ ] No Made of_________________________
Location: [ ] Interior [ ] Exterior Exits accessible [ ] Yes [ ] No
Any obstruction [ ] Yes [ ] No Termination/Discharge of Exits____________________________________________
Any enclosure provided [ ] Yes [ ] No Enclosure construction_____________________________________
Any opening [ ] Yes [ ] No Opening protected [ ] Yes [ ] No
Are fire door provided [ ] Yes [ ] No Width_____________ Fire door construction________________________
Door provided with vision panel [ ] Yes [ ] No If Yes. made of_____________________________________
Door equipped w/ Self-closing device [ ] Yes [ ] No Doors & enclosure proper rating [ ] Yes [ ] No
Doors open easily [ ] Yes [ ] No Self-closing device operable [ ] Yes [ ] No
Door equipped w/ panic hardware [ ] Yes [ ] No Operable [ ] Yes [ ] No
Door swing in the direction of exit travel [ ] Yes [ ] No Enclosure properly protected [ ] Yes [ ] No
Fire escape pressurized [ ] Yes [ ] No [ ] N/A If pressurized what type or method______________________
Date Last Tested____________________________________________________________________________________
B. HORIZONTAL EXITS
Width of door/s ________________ Construction_____________________ With vision panel [ ] Yes [ ] No
Door swing in the direction of egress travel [ ] Yes [ ] No With Self-closing device [ ] Yes [ ] No
Width of corridors or hall ways _________________________Construction __________________________________
Corridor walls extended from slab to slab [ ] Yes [ ] No Properly illuminated [ ] Yes [ ] No
Exit readily visible [ ] Yes [ ] No Clear and unobstructed [ ] Yes [ ] No
Properly marked w/ illuminated exit sign [ ] Yes [ ] No With illuminated directional sign [ ] Yes [ ] No
Properly located [ ] Yes [ ] No
C. RAMPS
Provided [ ] Yes [ ] No Type: [ ] Interior [ ] Exterior Width_________________ class _________________________
Railings provided [ ] Yes [ ] No Height from the floor _____________________ (Requirement: 91 cm)
Any enclosure provided [ ] Yes [ ] No Construction _____________________________________________________
Are fire doors provided [ ] Yes [ ] No Width__________ Fire door construction ___________________________
Door equipped w/ Self-closing device [ ] Yes [ ] No Door with proper rating [ ] Yes [ ] No

Door provided w/ vision panel [ ] Yes [ ] No If Yes, made of___________________________________________

Door swing in the direction of exit travel (when required) [ ] Yes [ ] No
Any obstruction ________________________ Termination/Discharge of exit _________________________________

D. AREA OF SAFE REFUGE

Provided [ ] Yes [ ] No Type: [ ] Interior [ ] Exterior Location___________________________________________
Any enclosure provided [ ] Yes [ ] No Construction __________________________________________________
Are fire door provided [ ] Yes [ ] No Width_______________ Fire door construction_______________________
Door equipped w/ self-closing device [ ] Yes [ ] No Door with proper rating [ ] Yes [ ] No
Door provided w/ vision panel [ ] Yes [ ] No If Yes, made of ________________________________________
Door swing in the direction of exit travel [ ] Yes [ ] No

VI. LIGHTINGS & SIGNS

A. EMERGENCY LIGHTS
Automatic Emergency Lights Provided [ ] Yes [ ] No Source of Power [ ] AC/DC [ ] Others____________________
No. of Units per Floor___________ Located at: Hallways _____________ Stairway Landings ____________________
Operational: [ ] Yes [ ] No Exit path properly illuminated [ ] Yes [ ] No
Tested Monthly: [ ] Yes [ ] No Minimum AEL Power Duration: at least one (1) hour
B. EXIT SIGNS
Exit Signs Illuminated [ ] Yes [ ] No Location ____________________________________________________
Source of Power [ ] AC/DC [ ] Others Readily visible [ ] Yes [ ] No
Minimum Letter Size ________________________ Min. Requirement: Height of 11.5 cm & width of 19.0 mm
Exit Route Plan posted on: Lobby/Hallways [ ] Yes [ ] No Rooms [ ] Yes [ ] No

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

Directional Exit Signs [ ] Yes [ ] No Location____________________________________________________

C. WARNING/SAFETY SIGNS
[ ]”No Smoking” [ ] “Dead End” [ ] Elevator Sign [ ] Keep Door Closed
Other, specify ______________________________________________________________________________________

VII. FEATURES OF FIRE PROTECTION

A. PROTECTION OF VERTICAL OPENINGS
Properly protected [ ] Yes [ ] No Atrium [ ] Yes [ ] No Fire Doors good condition [ ] Yes [ ] No
Elevator opening protected [ ] Yes [ ] No Pipe Chase opening protected [ ] Yes [ ] No
Aircon Ducts system with damper [ ] Yes [ ] No Dumb Waiter opening protected [ ] Yes [ ] No
Garbage Chute opening protected [ ] Yes [ ] No
Between Floor & Glass Curtain opening protected [ ] Yes [ ] No
Date Last Tested____________________________________________________________________________________
B. ALARM SYSTEM
Fire Alarm Provided [ ] Yes [ ] No Type: [ ] Manual [ ] Automatic Centralized [ ] Yes [ ] No
Location of Central Control ____________________________________________________________________________
No. of Bells per Floor ___________________ Location______________________________________________________
Coverage: [ ] Budding [ ] Air Handling Unit [ ] Portion. Specify________________ Monitored [ ] Yes [ ] No
Type of Initiation Device [ ] Smoke [ ] Heat [ ] Manual [ ] Water Flow [ ] Others_____________________________
No. of Pull Stations per Floor ________________ Max. Horizontal Distance Bet. Pull Stations: 61.0 m
Smoke Detectors [ ] Yes [ ] No No. of Units per Room_________________ Integrated [ ] Yes [ ] No
Heat Detectors [ ] Yes [ ] No No. of Units per Room_________________ Integrated [ ] Yes [ ] No
Power Source of Detectors [ ] AC/DC [ ] Others______________ Total Detectors per Floor____________________
Date Last Tested____________________________________________________________________________________
C. STANDPIPE SYSTEM
Type: [ ] Wet [ ] Dry Tank Capacity________________ Location_______________________________________
Siamese Intake Provided [ ] Yes [ ] No Location________________________________________________
Size _____________ No. of Units _______________________ Accessible [ ] Yes [ ] No
Fire Hose Cabinets Provided [ ] Yes [ ] No With Complete accessories [ ] Yes [ ] No
Location___________________________________________________________________________________________
No. of Units per Floor_____________ Size of Hose__________________ Length of Hose_________________________
(Note: Min Required Size of Riser & Distribution Pipe: 2 1/2 inch and 1 1/2 inch in diameter, respectively)
Type of Nozzle _______________________ Date Last Tested_______________________________________________
Fire Lane Provided: [ ] Yes [ ] No Location of nearest Fire Hydrant ____________________________________
D. FIRST AID FIRE PROTECTION EQUIPMENT (PORTABLE FIRE EXTINGUISHERS)
Type__________________ Capacity ____________________________ No. of Units______________________________
With PS Mark [ ] Yes [ ] No With ISO Mark [ ] Yes [ ] No
Properly Maintained [ ] Yes [ ] No Conspicuously Located [ ] Yes [ ] No Accessible [ ] Yes [ ] No
Other Types Provided, if any___________________________________________________________________________

E. AUTOMATIC FIRE SUPPRESSION SYSTEM (SPRINKLER SYSTEM)

Type of Extinguishing Agent Used____________ Jockey Pump Capacity___________ hp ____________GPM
Fire Pump Capacity: __________________ hp _____________GPM Tank Capacity________________ gallons
Maintaining Line Pressure ___________________ Farthest Sprinkler Head Pressure____________________________
Riser Size______________________ Type of Heads Installed________________________________________________
No. of Heads per Floor ___________________ Total_______________ Spacing of Heads ______________________
Location of Fire Department Connection ________________________________________________________________
Date Last Tested __________________________Conducted_________________________________________________
Plan Submitted ___________________________ Certificate of Installation_____________________________________
BFP AFSS Certificate payment under Section 13 B (5) and Fund Code No. D2531–151
F. FIREWALL
Building required with firewalls [ ] Yes [ ] No Provided [ ] Yes [ ] No
Any Opening [ ] Yes [ ] No

VIII. BUILDING SERVICE EQUIPMENT

A. Boiler Provided [ ] Yes [ ] No No. of Units provided________________________________________
Fuel: [ ] Diesel [ ] Kerosene [ ] Coal [ ] Bunker [ ] LPG Capacity________________________________________
Container: [ ] Above-ground [ ] Underground Location__________________________________________________
LPG Installation Covered with Permit [ ] Yes [ ] No Fuel with Storage Permit [ ] Yes [ ] No
B. Generator Set Provided [ ] Yes [ ] No [ ] Automatic [ ] Manual Fuel: [ ] Diesel [ ] Gasoline
Capacity ___________________ Location__________________ Dikes/Bund wall Provided [ ] Yes [ ] No
Container: [ ] Above-ground [ ] Underground Dispensing System [ ] By pump [ ] By gravity
Output Capacity__________________ kva Mechanical Permit ____________ Date Issued_________________
Fuel with Storage Permit [ ] Yes [ ] No Others (specify)____________________________________________
Automatic Transfer Switch Provided [ ] Yes [ ] No Time Interval_____ sec (Requirement: Max 10 secs)
C. Refuse (Garbage) Handling Facility: Provided [ ] Yes [ ] No
Enclosure provided [ ] Yes [ ] No Fire resistive [ ] Yes [ ] No
Fire protection provided [ ] Yes [ ] No Type___________________________________________________________
Frequency of collection/disposal___________ How collected______________________________________________
D. Electrical System
Is there any electrical hazard [ ] Yes [ ] No Specify location ____________________________________________
BFP-QSF-FSED-027 Rev. 01 (07.05.19) Page 3 of 4
 Republic of the Philippines
Department of the Interior and Local Government
Bureau of Fire Protection

E. Mechanical System
Is there any mechanical hazard [ ] Yes [ ] No Specify location____________________________________________
No. of elevators provided_____________________________________________________________________________
Fireman's elevator provided [ ] Yes [ ] No Fireman's key/switch provided [ ] Yes [ ] No
F.Other Building Service Systems
[ ] Water Treatment Facility [ ] Waste Water/Sewage Treatment Facility

IX. HAZARDOUS AREA

[ ] Kitchen [ ] Laundry [ ] Windowless Basement [ ] Storage Room [ ] Others_______________________
Separation Fire Rated [ ] Yes [ ] No Type of Fire Protection provided____________________________________
No. of Units______________ Capacity__________________ Accessible [ ] Yes [ ] No
Fuel Used_______________ Where Stored ___________________ Covered by BFP Permit______________________
Chimney: Made of ___________________ Spark Arrester____________ Smoke Hood___________________________
Presence of hazardous materials [ ] Yes [ ] No Properly stored and handled [ ] Yes [ ] No

Kinds Container Volume Location

1.________________ ________________________ ______________________ ______________________
2.________________ ________________________ ______________________ ______________________
3.________________ ________________________ ______________________ ______________________
Storage Permit for Flammables/Combustibles Covered by BFP Permit _________________________________________
Clearance of Stocks From Ceiling ______________________________________________________________________
Minimum Ceiling Clearance: 1.0m for Flammable Liquids and 0.5m for Combustible Materials

X. OPERATING FEATURES
Fire Safety Program (Under the supervision of the Chief Local Fire Service)
Fire Brigade Organization [ ] Yes [ ] No
Fire Safety Seminar [ ] Yes [ ] No
Employees trained in emergency procedures [ ] Yes [ ] No
Fire/Evacuation Drill [ ] Yes [ ] No
1st ______________________________________ 2nd ________________________________________

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

XII. 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-027 Rev. 01 (07.05.19) Page 4 of 4