Republic of the Philippines

Department of the Interior and Local Government

Bureau of Fire Protection
Regional Office 4A
Laguna Provincial Office
Biñan City Fire Station
Brgy. Poblacion, Biñan City, Laguna
(049) 511-9111 / binanfirestation@yahoo.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) ________________________________________________________________________________

MISCELLANEOUS 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
A. [ ] TOWERS
Fire Alarm Provided [ ] Yes [ ] No Smoke/Heat Detector Provided [ ] Yes [ ] No
AC/DC Emergency Lights Provided [ ] Yes [ ] No First Aid Fire Protection [ ] Yes [ ] No
Lightning Protection Provided [ ] Yes [ ] No Grounding System Provided [ ] Yes [ ]No
Type of Exits Required____________________ Doors _____________________________________________

B. [ ] PIERS AND WATER SURROUNDED STRUCTURES

C. [ ] VEHICLES AND VESSELS
D. [ ] UNDERGROUND STRUCTURE & WINDOWLESS BUILDING Specify usage ____________________

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

V. EXIT DETAILS
No. of Exits______________________________________________________ Remote [ ] Yes [ ] No
Minimum Requirement: No. of Exits: Two (2) units per floor
Location of Exit____________________________________________________________________________________
Maximum Travel Distance Requirement from Farthest Room: 30.5 m without AFSS & 46m with AFSS
Any Enclosure Provided [ ] Yes [ ] No Min of 2-hr fire rating- 4-storey or more, Min of 1 hr, fire rung- less than 4-storey
Fire Doors Provided [ ] Yes [ ] No
Self-Closing Mechanism [ ] Yes [ ] No Panic Hardware [ ] Yes [ ] No

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
Buildings with Mezzanine [ ] Yes [ ] No Mezzanine with proper exits [ ]Yes [ ] No
Corridors & aisles of sufficient size [ ] 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
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 ________________________________

BFP-QSF-FSED-022 Rev. 01 (07.05.19) Page 2 of 4

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

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. 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

IX. 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
Date Last Conducted: ________________________________________________________________________

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

BFP-QSF-FSED-022 Rev. 01 (07.05.19) Page 3 of 4

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

XI. 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-022 Rev. 01 (07.05.19) Page 4 of 4