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
This electronic form requires Microsoft “Word” software to complete.
You may e-mail your completed form to us as an attachment at:
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.
FIRESAFETY SELF-INSPECTION WORKSHEET FOR BUSINESSES
Occupancy Information
Date of Inspection:
Business Name:
Phone Number:
Business Address:
Printed Name of Person
Conducting Self-Inspection:
Phone Number:
Position:
Building Exterior
Yes No
N/A
1. Is a minimum 3-foot (3') clearance present around fire hydrants? 508.5.5
2. Is a Minimum 3-foot (3') clearance present around fire department connections?
Fire Department connection must be visible and unobstructed. 912.3
3. Are all caps in place on fire department connection? 912.6
4. Are address numbers posted according to City ordinance? Numbers shall be
3- inch or larger, contrasting color, visible from street, adjacent to principle
entrance and plainly visible. 505.1& Galesburg Municipal Code section 25-2
5. Are all sides of the building free from weeds, trash debris or combustible storage?
Outside waste accumulation is prohibited. 304.1
6. Are building keys up to date in Knox Box? 506.2
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Means of Egress
7. Are all exit signs operational and illuminated? 1027.3
8. Are all emergency lights operational? 1027.5
9. Are all exit doors and points of egress free of obstructions? 1028.3
10. Do marked exit doors operate from egress side? Physically test door. 1028
11. If any exit door has panic hardware, is that door free of any other locking devices?
The main exterior door permitted to be equipped with key-operated lock from the
egress side provided the lock is readily distinguishable as locked and sign posted
this door to remain unlocked when building is occupied. 1008.1.8.3 & 1008.1.9
12. Are stairwell and all other fire doors closed? Fire doors shall not be blocked open.
703.2.2
13. Are outdoor fire escapes maintained? 1027.16.7
Storage and General Housekeeping
14. Are oily rags stored in required self-closing metal cabinet and disposed of daily
after use? 304.3.1
15. Is all storage neat and orderly? 315.2
16. Are combustibles stored away from heat source such as a furnace, stove, water
heater, electric motors and other heat sources?315.2
17. Does storage height comply with the following: less than 12 feet in height; a
minimum 18 inch clearance from sprinkler heads; and a minimum of 2 feet
clearance from ceiling with no fire sprinklers? 315.2.1
18. Have combustibles been removed from boiler room, mechanical room and
electrical rooms? If not, this storage must be removed. 315.2.3
Flammable Storage
19. Are compressed gas cylinders secured from falling? 3003.5.3.
20. Are flammable liquids stored in approved closed metal cabinet? This applies to
quantities in excess of ten (10) gallons. 3404.3.4.4
21. Are gasoline and other flammable liquids stored in approved containers for type
of flammable liquid being stored? Maximum storage amount limit is 10 gallons.
3504.3.4.4
Electrical
22. Exposed electric wires, defective electric equipment, modified or damaged
equipment are not present in this structure. There are no open junction boxes or
open-wiring splices present. 605.1 and 605.6
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23. Is 30-inch clearance from electrical equipment maintained? 605.3
24. Are all electric room doors and electric panels labeled to identify what they
control? 605.3.1
25. Extension cords are not being used as a substitute for permanent wiring.
Extension cords shall not be extended through walls, ceilings or floors, or under
floor coverings, nor shall they be subject to environmental or physical impact.
605.5
26. Are extension cords plugged directly into an outlet? 605.5.1
27. Is the ampacity of the extension cords equal to or greater than the rated capacity
of the portable appliance being supplied by the cord? 605.5.2
28. Are extension cords maintained in good condition without splices, deterioration
or damage? 605.5.3
29. Are extension cords grounded when serving grounded portable appliances?
605.5.4
30. Are all portable electric space heaters UL Listed? Space heaters shall not be
plugged into extension cords and a 3 foot clearance shall be maintained from
combustibles.605.10
Fire Separations
31. Are all fire walls and smoke barriers being maintained? 703.1
32. Are all fire doors being maintained in an operational condition? Fire doors shall
not be blocked or obstructed or made inoperable. 703.2
33. Have all breaches, missing ceiling tile/holes in the wall or ceiling that could allow
fire into the hidden spaces been repaired or replaced? 703.1
Fire Protection Systems
Note: A minimum of 2A fire extinguisher is required for most new and existing occupancies. A travel
distance of less than 75 feet to the extinguisher is required. A good all around fire extinguisher rating
of 2A10BC will meet the fire extinguisher requirement for most buildings. Check with Galesburg Fire
Prevention or your fire extinguisher service company. 906.1
34. Are all required fire extinguishers present and operational? All extinguisher
gauges register in the green. All extinguishers must be readily accessible and
located in visible locations. 906.6
35. Is there a travel distance of less than 75 feet from any area in the building to a fire
extinguisher? 906
36. Have all extinguishers had annual required service inspection? 906.2
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37. Are all extinguishers mounted correctly? Mounting height of fire extinguishers
shall not be more than 5 feet to top of fire extinguisher and the bottom shall be a
minimum of 4 inches off the floor. If an extinguisher is over 40 pounds the
maximum height shall be 3.5 feet to the top of the unit. 906.9
38. Has the kitchen hood fire suppression system been maintained? Provide proof of
inspection and testing for past six months. 904.11.6.4
30. Are the hood and duct maintained in clean condition? 904.11.6.3
40. Is the sprinkler system “on” (activated to react in case of fire)? 901.4.4
41. Has the fire sprinkler system been maintained? Provide proof of annual
inspection, and test for the last year. 901.6
42. Has the fire alarm system been maintained? Provide proof of annual inspection
and test for the last year. 901.6
43. Is the fire alarm power light illuminated? 901.4.4
44. The fire alarm system is not in fire alarm or trouble? No alarm or trouble lights
illuminated on panel. 901.4.4
45. Is the fire alarm panel accurately labeled? 901.4
46. Are chimney and heating units maintained in safe condition? 603.6
If you answered “no” to any question, please correct the violation before returning this form. Please
also remember to include proof of required hood fire suppression, fire sprinkler and fire alarm
system maintenance with this form.
Comments:
Item #
Issue/Comment
Person Conducting Inspection (if not returning it by e-mail):
Signature:
___________________________________
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