Business Representative Name: ___________________________________________________
I do hereby refuse (Inspectors Name): ___________________________________________
authorized representative of the Fire Protection District, entry into my business
(Business Name): ________________________________________________________________
located at (Street address): ____________________________________________________
to conduct a fire inspection.

Authorized company official: ____________________________________________________
Title: ____________________________________________  Date: ______________________

The following conditions were observed in my attempt to secure entry:
	1. __________________________________________________________________________
	2. __________________________________________________________________________
	3. __________________________________________________________________________

Past inspections have disclosed few/several fire code violations.

Date of last inspection: ____________________
Occupancy Group: _______________________ Occupant Load: _________________________
Construction Type: _______________________ Life hazard: _________________________
Distance to adjacent occupancies or structures: _________________________________

       
INDEX Fire Prevention Organization

FPT 102 - Fire Prevention and Inspection // Instructor: Kevin M. Kolb        Slide #7