REPORT OF FIRE INSPECTION Chapel Hill Fire Department Telephone (919)968-2781

• Document No.

• Prepared by

  Select Dace Bergen - Fire Marshal Mary Blevins - Assistant Fire Marshal Thomas Gregory - Assistant Fire Marshal Darryl Rimmer - Assistant Fire Marshal Johnny Parker - Deputy Fire Marshal

  • Dace Bergen - Fire Marshal
  • Mary Blevins - Assistant Fire Marshal
  • Thomas Gregory - Assistant Fire Marshal
  • Darryl Rimmer - Assistant Fire Marshal
  • Johnny Parker - Deputy Fire Marshal

• Conducted on

  Date

• Additional Personnel

Information

• Business Name

• Phone

• Business #

• Address
  Address

• Suite #

• Grid #

• Owner/Manager

Property Manager

• Name

• Phone #

Sprinkler System

• Service Date

  Date

• Name Of Company

Fire Alarm System

• Service Date

  Date

• Name Of Company

Kitchen Supp. System

• Service Date

  Date

• Name Of Company

• Are there hazardous materials in quantities that must be reported according to right to know?

  YES

  NO

  N/A

Section 1: Life Safety Violations

• Locked Exits

  PASS

  FAIL

  N/A

• Blocked Exits

  PASS

  FAIL

  N/A

• Exit Access(es) Obstructed (less than 36 inches)

  PASS

  FAIL

  N/A

• Exit Lights Inoperable

  PASS

  FAIL

  N/A

• Combustible Storage In Exits, Aisles, or Under Stairs

  PASS

  FAIL

  N/A

• Kitchen Suppression System Requires 6 Month Service

  PASS

  FAIL

  N/A

• Unapproved Door Locks Or Latches

  PASS

  FAIL

  N/A

• Smoke Alarm / Fire Alarm Due For Annual Service / Inoperable

  PASS

  FAIL

  N/A

• Portable Unvented Fuel-Fired Heaters

  PASS

  FAIL

  N/A

• Emergency Lights Inoperable

  PASS

  FAIL

  N/A

• Fire/Sprinkler System Due For Annual Service / Inoperable

  PASS

  FAIL

  N/A

Section 2: Fire Code Violations

• Fire Extinguisher Service: Annual, 6yr, 12yr

  PASS

  FAIL

  N/A

• Improper Use Of Extension Cords

  PASS

  FAIL

  N/A

• Required Clearance Around Electrical Panel

  PASS

  FAIL

  N/A

• Compressed Gas Cylinders Unsecured

  PASS

  FAIL

  N/A

• General Clean Up Of Area Or Room

  PASS

  FAIL

  N/A

• Replace Broken Or Missing Ceiling Tiles

  PASS

  FAIL

  N/A

• 24 Inch Clearance Between Storage And Ceiling

  PASS

  FAIL

  N/A

• 36 Inch Clearance Around Gas Appliances

  PASS

  FAIL

  N/A

• Open Junction Boxes/Spliced Wires

  PASS

  FAIL

  N/A

• Address Numbers Visible

  PASS

  FAIL

  N/A

• Loose Electrical Wires

  PASS

  FAIL

  N/A

• FDC Location Street Side Of BLDG/Unobstructed

  PASS

  FAIL

  N/A

• Mounted Fire Extinguishers

  PASS

  FAIL

  N/A

• Class K Extinguisher (if applicable)

  PASS

  FAIL

  N/A

• Occupant Load Posted/Visible

  PASS

  FAIL

  N/A

• Holes In Walls

  PASS

  FAIL

  N/A

Section 3: List Additional Violations Or Information

Re-inspection/Fine Information

• Re-inspection Date Scheduled

  Date

• Date Of Re-inspection

  Date

• Pay Fine Listed Below to the Town Of Chapel Hill Revenue Office Located At 306 N. Columbia Street, Chapel Hill, NC 27516 (acct#1004646410)

• Permit Required for the Following

• Pay your Permit Fee Listed Below by mailing or delivering a copy of this inspection in addition to your payment to the Town Of Chapel Hill Revenue Office Located At 306 N. Columbia Street, Chapel Hill, NC 27516 (acct#1004646410)

• Inspectors Signiture

  Sign

• Business Representatives Signature

  Sign