STATE OF CALIFORNIA FORESTRY AND FIRE PROTECTION
See instructions on reverse.
FIRE SAFETY INSPECTION REQUEST
STD. 850 (REV. 10/2019)
AGENCY CONTACT'S NAME TELEPHONE NUMBER REQUEST DATE PROGRAM
EVALUATOR'S NAME REQUESTING AGENCY FACILITY NUMBER REQUEST CODE
CODES
LICENSING
AGENCY
NAME AND
ADDRESS
1. ORIGINAL A. FIRE CLEARANCE
2. RENEWAL B. LIFE SAFETY
3. CAPACITY CHANGE
4. OWNERSHIP CHANGE
5. ADDRESS CHANGE
6. NAME CHANGE
7. OTHER
AMBULATORY
NONAMBULATORY
BEDRIDDEN TOTAL CAPACITY
CAPACITY
PREVIOUS CAPACITY
CAPACITY
PREVIOUS CAPACITY
CAPACITY
PREVIOUS CAPACITY
FACILITY NAME LICENSE CATEGORY
STREET ADDRESS (Actual Location)
NUMBER OF BUILDINGS
CITY
RESTRAINT
FACILITY CONTACT PERSON'S NAME
FACILITY CONTACT PERSON'S TELEPHONE NUMBER
HOURS
SPECIAL CONDITIONS
TO BE COMPLETED BY INSPECTING AUTHORITY
FIRE
AUTHORITY
NAME AND
ADDRESS
INSPECTOR'S NAME (Typed or Printed) TELEPHONE NUMBER
INSPECTION DATE INSPECTOR'S SIGNATURE (Typed or Printed)
CFIRS NUMBER OCCUPANCY CLASS
CLEARANCE /DENIAL CODE
CODES
1. FIRE CLEARANCE GRANTED
2. FIRE CLEARANCE DENIED
A. EXITS
B. CONSTRUCTION
C. FIRE ALARM
D. SPRINKLERS
E. HOUSEKEEPING
F. SPECIAL HAZARD
G. OTHER
EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS
Clear
Print
STATE OF CALIFORNIA FORESTRY AND FIRE PROTECTION
FIRE SAFETY INSPECTION REQUEST
STD. 850 (REV. 10/2019) (REVERSE)
INSTRUCTIONS
This form is designed for use with a window envelope
Licensing or Requesting Agencies--Complete the following 19 sections on this form
before submitting it to the fire authority having jurisdiction.
1. AGENCY CONTACT, 2. TELEPHONE NUMBER,
5. EVALUATOR.
Enter the name and telephone number
of agency contact person.
3. PROGRAM.
Licensing agency use.
4. REQUEST DATE.
Enter date request was prepared.
6. REQUESTING AGENCY FACILITY NUMBER.
This
is the file number assigned by the licensing agency.
7. REQUEST CODE.
Use the seven codes shown and insert
the appropriate number in the box following "Request
Code". If NAME CHANGE, please list previous name. Insert
date of original request is other than an original.
8. AGENCY NAME AND ADDRESS.
Enter the name and
address of the licensing facility requesting the inspection.
9. AMBULATORY--NONAMBULATORY--BEDRIDDEN.
Capacity:
Insert in the appropriate section, the capacity
of licensed ambulatory or nonambulatory oc
-
cupants covered by this request.
Previous
If request is for renewal or capacity change,
Capacity:
insert capacity of previous clearance.
Total
Show total licensed capacity. If the facility
is
Capacity:
intended to house part ambulatory, nonambu
-
latory, and part bedridden, show the total of
the three types of occupants.
10. FACILITY NAME. Insert the name of the facility as it
will appear on the license. List identifying sub name if
known (i.e., Hacienda Corp/Medina Lodge).
11. LICENSE CATEGORY.
Insert the category of license
being sought as it will appear on the license certificate.
12. ADDRESS.
In
sert street address and city only. A post
office box is not acceptable as only location.
13. NUMBER OF BUILDINGS.
Insert the total number of
buildings to be used for housing of the occupants covered
by
the license.
14. RESTRAINT.
Indicate if physical restraint (locked in a
room or the building) is to be used in the housing of the
occupants.
15.
FACILITY CONTACT PERSON--TELEPHONE
NUMBER. Indicate the name and telephone number of
the responsible individual at the facility to be contacted
by the fire authority.
16. HOURS.
Indicate the number of hours the occupants are
housed at the facility (less than 24 or 24+).
17. SPECIAL CONDITIONS.
Indicate any conditions
unique to this request. As an example, if the inspection
request is for one building in a multi-
building facility.
F
IRE AUTHORITY CONDUCTING THE INSPECTION--COMPLETE THE FOLLOWING:
18. F
IRE AUTHORITY
, NAME AND ADDRESS. Insert th
e
name and address of the fire authority where the facility is
located.
19. CLEARANCE/DENIAL CODE.
Use the two codes: 1
for clearance granted, and 2 for clearance denied. I
f denied,
also include the appropriate letter code. As an example,
Denial based upon exiting would be coded 2A.
20. INSPECTOR'S NAME.
Print the initial of the inspector's
first name and full last name; insert the telephone num
ber
where the inspector may be contacted.
21. CFIRS I.D. NUMBER.
Insert the fire department's number
assign
ed by California Fire Incident Reporting System.
22. OCCUPANCY CLASSIFICATION.
Use California
Building Code occupancy classifications and insert the
occupancy determined by the inspector.
23.
INSPECTION DATE.
Enter the actual date of the in
-
spection.
24. INSPECTOR'S SIGNATURE.
To be signed by the
inspector conducting the inspection.
25. EXPLAIN DENIALOR SPECIAL CONDITIONS.
If
clearance code #2 is used, briefly explain reason. This
space is also to be used to specify
any additional
limitations placed by the fire authority, such as the use of
certain floors or sleeping rooms approved for
nonambulatory clients.
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