Fillable Form 1: Fire Suppression System Deficiency Report (Office of Innovation and Technology)

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Form 1: Fire Suppression System Deficiency Report (Office of Innovation and Technology)

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BROWSE OFFICE OF INNOVATION AND TECHNOLOGY (PA) FORMS

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TP_013_F Fire Suppression System Deficiency Form
Fire Suppression System Deficiency Report
When deficiencies are not corrected within 45 days of the certification inspection or testing, the
Contractor must submit this deficiency report to the Department of Licenses and Inspections.
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Address: ___________________________________________________________________________________
Name: _____________________________________________________________________________________
Address: ___________________________________________________________________________________
Email: _______________________________________________ Phone: ______________________________
Building Owner/Owner’s
Agent Information
Provide the contact information for
the building owner/owner’s agent.
Property Information
Provide the address of the
property where the deficiency is
being reported.
Contractor and Inspector
Information
Provide the names of the
Contractor and inspector.
Contractor Name: ____________________________________________________________________________
Inspector Name: ____________________________________________________________________
Date of Inspection: _____________________________
Deficiency Information
Provide information on any major
deficiencies.
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Major Deficiencies:
☐ System out-of-service / impaired ☐ Quick opening device inoperative
☐ Fire pump failure ☐ Dry pipe / preaction system failed
☐ Alarms failed ☐ Sprinkler painted or obstructed
☐ City supply inadequate ☐ Recalled sprinklers installed
☐ F.D.C. not compliant
☐ Other (describe): _________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Annual Certification Report” option in eCLIPSE.
Declaration & Signature
The Deficiency Form must be presented by the Contractor to the building owner/agent upon completion. By signing below, I certify that the above Sprinkler System,
tested in accordance with NFPA 25 and the Philadelphia Fire Code, failed the annual inspection. Systems out of service must be reported immediately to the Philadelphia
Fire Department at 215-922-6000.
S
ignature of Inspector: ___________________________________________________________ Date: _________________________
Sign
ature of Building Owner/Owner’s Agent: _________________________________________ Date: _________________________
Building is:
☐
Commercial
☐
Residential
☐
Mixed-Use (Commercial/Residential)
Number of Stories: ________________
Building Occupancy
Provide the type of occupancy of the
building and the number of stories.
System Information
Automatic Fire Suppression System:
☐
Sprinkler
☐
Foam
☐
Fire Hydrant
☐
Other
Standpipe System: ☐Class I ☐Class II ☐Class III
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Form 1: Fire Suppression System Deficiency Report (Office of Innovation and Technology)

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Completed 1 February 2022

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