RENEWAL OF FSIC CHECKLIST
I. REFERENCE:
Inspection Order No. (lO)
*
Business Identification Number (BIN) / Business Account Number (BAN)
*
Date lssued
*
-
Month
-
Day
Year
Date lnspected
*
-
Month
-
Day
Year
II. NATURE OF INSPECTION CONDUCTED (Check appropriate box)
NATURE OF INSPECTION CONDUCTED (Check appropriate box)
*
FSIC for Business Permit
FSIC for Certificate of Annual Inspection (PEZA)
Verification Inspection for Compliance
NTC
NTCV
Abatement
Closure
Other
FSI Name
*
FSI Email Address
*
***REMARKS ON ESTABLISHMENT***
*
Please Select
OPEN
PERMANENTLY CLOSED/RETIRED ESTABLISHMENT
CLOSED DUE TO COMMUNITY QUARANTINE GUIDELINES
CANNOT BE LOCATED
BUSINESS TRANSFERRED
NOT OPERATIONAL
NOT EXISTING
CHANGE OF BUSINESS NAME
DOUBLE IO/ALREADY INSPECTED
RESCHEDULED
REFUSED ENTRY
Submit
III. REQUIREMENT
Fire Safety Maintenance Report (FSMR)
Yes
No
N/A
IV. GENERAL INFORMATION
Business Identification Number (BIN) / Business Account Number (BAN)
Name of Building
Address
Business Name
Nature of Business
EX: SARI-SARI STORE, RETAILER, CLINIC, GEN. MDSE, SPA
Name of Owner/Representative
Email Address of Owner/Representative
Phone Number of Owner/Representative
Ex: 09191234567
•
FSIC for Renewal of Business Permit / Certificate of Annual Inspection (PEZA)
• Certificate of Fire Drill
Date lssued
-
Month
-
Day
Year
• Business Permit No.
Date lssued
-
Month
-
Day
Year
• Fire Insurance Policy No. (If any)
Date lssued
-
Month
-
Day
Year
V. FIRE SAFETY MEASURES ASSESSMENT OF THE BUILDING/STRUCTURES/FACILITY
Total Floor Area
Building Height
General Occupancy Classification
Please Select
Assembly
Educational
Day Care
Health Care
Detention and Correctional
Residential
Residential Board and Care
Mercantile
Business
Industrial
Storage
Special Structure
1. Building Construction
Building Construction
Walls/Ceiling Interior Finish
Floor Interior Finish
Previous After Inspection Report
Date of Previous After Inspection Report
-
Month
-
Day
Year
Date
Compliant
Yes
FSIC No. (Latest)
Date
-
Month
-
Day
Year
Date
Present/Actual Inspection
Compliant
Yes
No
No changes from previous inspection
With Changes
With Changes
Renovation
Repair
Additional
2. Sectional Occupancy
Previous After Inspection Report
Compliant
Yes
State the no. of floors based on the previous inspection:
Present/Actual Inspection
Compliant
Yes
No
No changes from previous inspection
With Changes
With Changes
Renovation
Repair
Additional
State Particular Floor
State Particular Floor
3. General Occupancy Specification
Previous After Inspection Report
Compliant
Yes
State the previous type of occupancy
Present/Actual Inspection
Compliant
Yes
No
No changes from previous inspection
Change of Occupancy
State the type of occupancy
4. Means of Egress
Previous After Inspection Report
Compliant
Yes
See attached previous report
Present/Actual Inspection
Compliant
Yes
No
No changes from previous inspection
With Changes
With Changes
Renovation
Repair
Additional
State Particular Changes
State Particular Changes
5. Exits
Previous After Inspection Report
Compliant
Yes
See attached previous report
Present/Actual Inspection
Compliant
Yes
No
No changes from previous inspection
With Changes
With Changes
Renovation
Repair
Additional
State Particular Violation
State Particular Violation
6. Signs. Lighting and Exit Signage
Signs, Lighting and Exit Signage
Marking of Means of Egress
Marking of Means of Egress (Emergency Evacuation Plan)
Previous After Inspection Report
Marking of Means of Egress Compliant
Yes
Marking of Means of Egress (Emergency Evacuation Plan) Compliant
Yes
Present/Actual Inspection
Marking of Means of Egress Compliant
Yes
No
No changes from previous inspection
State Particular Violation
State Particular Violation
Marking of Means of Egress (Emergency Evacuation Plan) Complaint
Yes
No
No changes from previous inspection
State Particular Violation
State Particular Violation
7. Illumination of Means of Egress
Previous After Inspection Report
Compliant
Yes
See attached previous report
Present/Actual Inspection
Compliant
Yes
No
No changes from previous inspection
State Particular Violation
State Particular Violation
8. Hazard Contents
Hazard Contents
Hazard Classification
Other Flammable Liquids
Miscellaneous Hazard (Mechanical Equipment Room, Storage, Supply Room)
No Smoking Signages
Storage of Gasoline/Diesel Storage in Proper Place
Previous After Inspection Report
Compliant
Yes
See attached previous report
Present/Actual Inspection
Compliant
Yes
No
No changes from previous inspection
Maximum Allowable Quantity
No Additional Fire Protection
No MSDS
No Proper Storage
9. Housekeeping
Housekeeping
Maintenance
Storage
Waste Disposal
Previous After Inspection Report
Compliant
Yes
See attached previous report
Present/Actual Inspection
Compliant
Yes
No
No changes from previous inspection
State Particular Violation
State Particular Violation
10. Fire Protection
Fire Protection
Automatic Fire Protection
Wet Standpipe/Fire Hose Cabinet
Fire Pump
Fire Detection and Alarm Communication System
Fire Alarm Facilities
Location
Alarm Panel
Please specify below
Previous After Inspection Report
Compliant
Yes
See attached previous report
Present/Actual Inspection
Compliant
Yes
No
No changes from previous inspection
Good and Operational Condition
State Particular Violation
State Particular Violation
11. First Aid Fire Protection
Previous After Inspection Report
Compliant
Yes
See attached previous report
Present/Actual Inspection
Compliant
Yes
No
No changes from previous inspection
Good and Operational Condition
Need additional Fire Extinguisher
Location of additional Fire Extinguisher
No. of Fire Extinguisher
12. Building Service Equipment
12. Building Service Equipment
Utilities
Smoke Control System/Smoke Management
Rubbish Chutes/Laundry Chutes/ Flue-Fed Incinerators
Previous After Inspection Report
Compliant
Yes
See attached previous report
Present/Actual Inspection
Compliant
Yes
No
No changes from previous inspection
State Particular Violation
State Particular Violation
13. Fire Safety Maintenance Report (FSMR)
13. Fire Safety Maintenance Report (FSMR)
Passive Fire Protection (a. Fire Door, b. Fire Walls, c. Compartmentation, d. Horizontal Exits, e. Stairs, f. Ramps, g. Exit Passageways)
Active Fire Protection (a. Automatic Fire Suppression, b. Fire Detection Alarm & Communication System, c. Wet Standpipe, d. Smoke Control System/ Pressurization)
Previous After Inspection Report
Compliant
Yes
Submitted Date
FSMR signed and certified by
Present/Actual Inspection
Compliant
Yes
No
FSMR signed and certified by
Submitted
Yes
No
VI. DEFECTS/DEFICIENCIES (Attached pictures, sketch and others)
DEFECTS/ DEFICIENCIES
VII. RECOMMENDATIONS
For Issuance of
FSIC For Business Permit (Renewal)
FSIC for Certificate of Annual Inspection (PEZA)
Notice to Comply
Notice to Correct Violation
Closure Order
Abatement Order
Closure Order for the Non-payment of Administrative Fine
FSI Recommendation
Please Select
FSIC For Business Permit (Renewal)
FSIC for Certificate of Annual Inspection (PEZA)
Notice to Comply
Notice to Correct Violation
Closure Order
Abatement Order
Closure Order for the Non-payment of Administrative Fine
•
Comply the following DEFFECTS/DEFICIENCIES stated above.
•
Secure the following Fire Safety Clearance/s
Secure the following Fire Safety Clearance/s
•
Pay the corresponding Fire Code Fees including the fees for Fire Safety Clearances.
AMOUNT PAID
Kindly collect the remaining amount if it is less than Php500
O.R. NUMBER
Date of Payment
-
Month
-
Day
Year
FIRE SAFETY INSPECTION CERTIFICATE
FOR CERTIFICATE OF OCCUPANCY
FOR BUSINESS PERMIT (NEW/RENEWAL)
Other
THIS CERTIFICATION IS VALID FOR
Please Select
issuance of FSIC for business permit only
issuance of FSIC for occupancy permit only
ADDRESS DESCRIPTION
ACKNOWLEDGE BY:
Name of Owner/Representative
Owner/ Representative Signature
Signature of Owner/Representative
Date
-
Month
-
Day
Year
Fire Safety Inspector(s) NAME
FSI Signature
Fire Satey Inspector
FSI Email Address
C,FSES Email Address (For Recommendation)
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Submit
FOR CHIEF OF FIRE SAFETY ENFORCEMENT SECTION
Please enter verification code
CHIEF, FSES RECOMMENDATION
RECOMMEND ISSUANCE OF FSIC
RECOMMEND ISSUANCE OF NTC
Chief, FSES Signature
CFM Email Address (For Approval)
Preview PDF
Submit
FOR CFM/MFM (ISSUANCE OF NTC)
Please enter verification code
APPROVAL(NTC)
APPROVED
DISAPPROVED
Date of Approval(NTC)
-
Month
-
Day
Year
CFM/MFM Signature(NTC)
Preview PDF
Submit
C,FSES Email Address(NTC)
Email Address of Owner/Representative (NTC)
NTC Serial Number
NTC Serial Number Generator
NTC INVALID FSIC
if disapproved(ntc)
FOR CITY/MUNICIPAL FIRE MARSHAL
Please enter verification code
APPROVAL
APPROVED FSIC
DISAPPROVED FSIC
Date of Approval
-
Month
-
Day
Year
Date
CFM/MFM Signature
Preview PDF
Submit
C,FSES Email Address
Email Address of Owner/Representative
Date+1 year
-
Month
-
Day
Year
Date
FSIC Serial Number
FSIC Serial Number Generator
if disapproved
Should be Empty: