Information
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Document No.
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Prepared by
- Dace Bergen - Fire Marshal
- Mary Blevins - Assistant Fire Marshal
- Thomas Gregory - Assistant Fire Marshal
- Darryl Rimmer - Assistant Fire Marshal
- Johnny Parker - Deputy Fire Marshal
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Conducted on
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Additional Personnel
Information
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Business Name
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Phone
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Business #
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Address
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Suite #
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Grid #
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Owner/Manager
Property Manager
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Name
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Phone #
Sprinkler System
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Service Date
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Name Of Company
Fire Alarm System
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Service Date
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Name Of Company
Kitchen Supp. System
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Service Date
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Name Of Company
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Are there hazardous materials in quantities that must be reported according to right to know?
Section 1: Life Safety Violations
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Locked Exits
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Blocked Exits
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Exit Access(es) Obstructed (less than 36 inches)
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Exit Lights Inoperable
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Combustible Storage In Exits, Aisles, or Under Stairs
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Kitchen Suppression System Requires 6 Month Service
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Unapproved Door Locks Or Latches
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Smoke Alarm / Fire Alarm Due For Annual Service / Inoperable
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Portable Unvented Fuel-Fired Heaters
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Emergency Lights Inoperable
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Fire/Sprinkler System Due For Annual Service / Inoperable
Section 2: Fire Code Violations
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Fire Extinguisher Service: Annual, 6yr, 12yr
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Improper Use Of Extension Cords
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Required Clearance Around Electrical Panel
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Compressed Gas Cylinders Unsecured
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General Clean Up Of Area Or Room
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Replace Broken Or Missing Ceiling Tiles
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24 Inch Clearance Between Storage And Ceiling
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36 Inch Clearance Around Gas Appliances
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Open Junction Boxes/Spliced Wires
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Address Numbers Visible
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Loose Electrical Wires
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FDC Location Street Side Of BLDG/Unobstructed
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Mounted Fire Extinguishers
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Class K Extinguisher (if applicable)
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Occupant Load Posted/Visible
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Holes In Walls
Section 3: List Additional Violations Or Information
Re-inspection/Fine Information
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Re-inspection Date Scheduled
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Date Of Re-inspection
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Pay Fine Listed Below to the Town Of Chapel Hill Revenue Office Located At 306 N. Columbia Street, Chapel Hill, NC 27516 (acct#1004646410)
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Permit Required for the Following
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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)
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Inspectors Signiture
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Business Representatives Signature
