Texas Department of Aging
and Disability Services
Form 5606
May 2014-E
Life Safety Code Certification
Street Address:
City:
County:
I am a representative of the fire safety authority having jurisdiction for the address shown above and based upon
an inspection of the residence located at that address,
I certify that the residence is in compliance with applicable portions of National Fire
Protection Association (NFPA) 101: Life Safety Code (LSC), as determined by the local
fire safety authority.
Edition of NFPA 101 used:
Occupancy Chapter used:
or
I certify that the residence is in compliance with applicable portions of the International
Fire Code (IFC), as determined by the local fire safety authority.
or
The fire safety authority having jurisdiction for the address shown above is unable or
unwilling to inspect for certification using the code (LSC or IFC) for that jurisdiction.
Local Fire Safety Authority:
Signature
Printed Name
Title
Organization/Entity:
Date: