City of Galesburg
Operating Under Council – Manager Government Since 1957
Galesburg Fire Department
Fire Prevention Bureau
150 South Broad St.
Galesburg, Illinois 61401
Office: 309-345-3756
Fax: 309-343-1340
Email: Fireinsp2@ci.galesburg.il.us
You may complete this form on your computer by going to www.ci.galesburg.il.us , click on
“Documents and Forms” under the “Quicklink” heading. In the search box enter:
inspection. The Self-Inspection Worksheet icon will appear in the list. Open the document,
save it to your computer, fill in the blanks, and save it. You may e-mail it to us as an
attachment to: Fireinsp2@ci.galesburg.il.us.
If you complete this form in hard copy, return it by fax to 309-342-1340 or mail it to
Galesburg Fire Department, at the address shown to the left.
SELF-INSPECTION WORKSHEET FOR BUSINESSES
Business Name:
Date of Inspection:
Address:
Phone :
Person Conducting Inspection:
Phone :
Position:
Building Exterior
Y
N N/A
Email:
List includes most common safety concerns. All code references are from the International
Fire Code 2006 freely viewable at www. iccsafe.org . Additional information on city
website.
1. Are all sides of the building free from combustible weeds / debris or storage? 304.1
2. Are address numbers posted a minimum 3- inch, contrasting color, visible from street,
adjacent to principle entrance and plainly visible. 505.1 & GMC 97.002
3. Buildings with fire sprinklers/standpipes: Do you have a 3-foot clearance around fire
department connections and are caps in place? 912.3
Means of Egress
4. Are all exit signs operational and illuminated? (press test button) 1027.3
5. Are all emergency lights operational? (press test button) 1027.5
6. Are all exit doors and points of egress free of obstructions?
1028.3
7. Manually operated flush bolts or surface bolts eliminated? 1003.3.1.8.1
8. Are stairwell and all other fire doors closed? 703.2
9. Are outdoor fire escapes maintained?
1027.16.7
Storage and General Housekeeping
10. Is all storage neat and orderly? 315.2
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Y
N N/A
11. Are combustibles stored away from heat source such as a furnace, stove, water heater,
electric motors and other heat sources? 315.2
12. Is storage less than 12 feet in height; 18 inches below sprinkler heads; and a minimum of
2 feet below ceiling? 315.2.1
13. Have combustibles been removed from boiler room, mechanical room and
electrical rooms? 315.2.3
14. Are compressed gas cylinders secured from falling? 3003.5.3
15. No flammable liquids in basement and have permit if >5 gallons? (10 gallons or more
must be stored in approved closed metal cabinet) 105.6.16, 3404.3.4.4 & 3404.3.5.1
16. Fueled equipment not stored or operated inside (exceptions: service stations & fire
sprinkled buildings in approved locations with < 10 gallons). 313.1
17. Garbage cans > 40 gallons stored inside must be non-combustible with lids. 304.3.2
Electrical
18. Exposed electric wires, defective electric equipment, modified or damaged
equipment are not present. There are no open junction boxes or open-wiring splices.
605.1 and 605.6
19. Is there 30-inch clearance in front of electrical panels? 605.3
20. Are all electric room doors and electric panels labeled to identify what they
control? 605.3.1
21. Extension cords are in good condition and used only with portable appliances and not
extended through walls, ceilings, floors, or under rugs and plugged directly to an outlet.
605.5
22. Power strips are fused, UL listed, and plugged directly into outlets. No multi-plug
adaptors. 605.4
23. Are all portable electric space heaters UL Listed, plugged directly to an outlet and a 3
foot clearance maintained from combustibles? 605.10
Building Fire Protection
24. Have all breaches, missing ceiling tile/holes/pipe chase in the wall or ceiling that could
allow fire into the hidden spaces been repaired or replaced? 703.1
25. Minimum 2A fire extinguisher mounted and visible with gauge in green and
inspection tag < 1 year old, within 75 ft. walking distance to all areas of building? 906.1
26. Does the kitchen hood fire suppression system have an inspection tag < 6 months old?
904.11.6.4
27. Are the hood and duct maintained in clean condition? 904.11.6.3
28. Does the sprinkler system gauge read > 30 PSI? 901.4.4
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29. Is the fire alarm power light on with no alarm or trouble indicators on the panel? 901.4.4
Y
N N/A
30. Are the zones and/or detector locations of your fire alarm clearly labeled, diagrammed,
or digital readout so an activated detector can be quickly identified? 901.4
31. Do you have documentation of “Fire Safety Plan”& “Fire Evacuation Plan” and fire drills
(requirement varies by building use and size). 405 & 406
32. Do you have all necessary operational fire permits (some listed below)? 105.1.1
33. Smoking allowed in approved areas only. 308.2.1
Note: Documentation required for annual tests of sprinklers, standpipes, fire alarms, and rolling/sliding
fire doors is handled under our FPSR tracking and can be forwarded to fireinsp2@ci.galesburg.il.us
Checklists Permit Specific
Assembly Permit (“Assembly” = > 49 occupant load):
Y
N N/A
1A. At least 2 exits out of assembly
with exits signs and emergency lighting.. 1019.1,
4M. Combustible weeds / debris 10
ft from fuel handling equipment. 2205.7
5M. Warnings on signs visible to
each dispenser (“No smoking”, etc.) 2205.
1011.1 & 1006.
Lumber Yard Permit
2A. Do doors from assembly swing in
direction of exit? 1008.1.2
Y
3A. Do doors with magnetic holdopen devices release with alarm and close
completely? 703.2.
4A. No latch on exit door other than
panic hardware. 1008.1.9
N N/A
1L. Fire Truck access to all sides of
storage (20 ft wide 13 ft ht) 1903.6
2L. Lumber secured by minimum 6 ft
fence. 1909.4
3L. Sawdust control system effective
with proper grounding and bonding. 1903
5A. Exit passageways min. 44 inches.
1021.2
4L. Fire extinguisher within 50 ft of
saw. 1904.2
6A. Is the occupant load posted?
(required if entertainment venue) 1004.3
5L. Systematic cleaning of entire
area affected by sawdust. 1903.3.1
Motor Fuel Dispensing Permit
6L. Fire sprinklers required in
woodworking areas > 2500 sq ft (excluding
storage) established after 7/15/2002. 903.2.3.1
1M. Emergency fuel disconnect
required 20-100 ft of dispenser – marked and
visible. 2203.2
Repair Garage Permit
2M. Dispensing devices are in clear
view of attendant. 2204.2.4
1R. Machine used to clean parts is
listed. 2211.2.1
3M. Fire extinguisher within 75 ft of
all dispensers. 2205.5
2R. Oily waste placed in self-closing
metal cans.
Page 3 of 5
3R. Spray finishing only if have permit
or paint is non-combustible. 2211.2. 2211.2.3.2
4LP. Containers stored so relief valve
up in vapor space. 3809.3
4R. Ignition sources located >18
inches above the floor. 2211.
5LP. Containers secured from
tampering and vehicles. 3809.13
5R. Pits/basements are ventilated.
2211.4.3
Flammable Finish Application Permit
6R. Used motor oil containers must
have spill protection if > 55 gallon containers or
> 1,000 gallon aggregate. 2211.2.2.1
Hot Works Permit (welding):
Y
N N/A
1H. Person designated to ensure hot
works safety and maintenance of records of
“pre-work check” reports. 2603.5
Y
N N/A
1F. Spraying of flammable or
combustible finishes done in spray room
meeting the International Building Code or a
spray booth NFPA 33 listed, both with
automatic fire extinguishing systems; or limited
to 9 sq ft surface area. 1504
2F. 3 ft clearance around spray
booths. 1504.3.2.5
2H. Is area of cutting and welding
restricted? 2601.3
3F. Fire Extinguisher minimum
4A40B within 30 ft. of finishing area. 1504.4.1
3H. Fire extinguisher minimum
2A:20BC within 30 ft even when work is off
location? 2604.2.6
4F. Protect fire sprinkler heads with
approved lightweight bags and replace if
heavily coated. 1504.5.2
LP Storage / Refill Station Permit
5F. Safe distances maintained from
open flames, sparks, hot surfaces, smoking
areas, non-explosion proof wiring. 1503
1LP. Containers not stored on roofs,
in basement or pit. 3809.6/
2LP. Storage kept 10 ft from building
openings (5 ft if 2 exits), LP dispensing stations,
and combustible materials; and 20 ft from
gasoline dispensers. 3809. 12
6F. Ventilation working in vapor
areas. 1504.7
3LP. Mounted fire extinguisher
minimum 40BC within 30 ft of storage. 3808. 2
If you answered “no” to any question, please correct the violation before returning this form or add
a comment as to your plans to correct.
Item #
Comments
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Signature of Person Conducting Inspection: ___________________________________
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