Name:       

Address:    

Town:                State:                Zip:  

Telephone:      (Ex:856-555-5555)

Do you own or rent your home?         Select One I own my home I rent my home.

If you are a tenant, please complete the following.

Landlord Name: 

Address:   

Town:             State:             Zip:  

Telephone:   (Ex:856-555-5555)

MY HOME

Year Built (if known):                    Number of Stories:     Select One 1 Story 2 Stories 3 Stories 4 or More Stories

Does your home have a smoke detector?     Select One Yes No   If yes, does it work?     Select One Yes No

Does your home have carbon monoxide detectors?     Select One Yes No   If yes, does it work?     Select One Yes No

Does your home have:  Basement     Select One Yes No   Finished Attic     Select One Yes No   Crawl Space     Select One Yes No

Is it Equipped with the following?

     Natural Gas Dryer     Select One Yes No      Natural Gas Heater/Furnace     Select One Yes No

     Gas Stove     Select One Yes No       Gas Hot Water     Select One Yes No      Oil Furnace     Select One Yes No

     Fireplace/Woodstove     Select One Yes No      Portable Kerosene Heater     Select One Yes No

     Attached Garage      Select One Yes No

Development Name: 

To submit this application, click the Submit Application button below.  To start over, click Clear Application.

 

After you submit this application, you will receive a conformation page to print for your records.

For Fire Marshal Use Only

FM DETERMINATION

Circle Answer

Eligible:  Yes     No

Referred to Rental Owner for corrective action:  Yes

Appointment Date: ______________________________________________________________

Appointment Time:  ______________________________________________________________

Contact Name:  ______________________________________________________________

Contact Number:  ______________________________________________________________

Company/Inspector Assigned:  ______________________________________________________________