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| General |
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| Name of Person Completing this form:
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| Submitter's E-Mail Address:
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| Date Submitted:
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04/27/2024 0210 |
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| Location Information |
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| Complex, Facility or Business Name:
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| Owners Name:
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| Mailing Address, City, State:
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| Is this a:
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Residence
Business
Apartment Building
School
Group Home
Religious Facility
Municipal Building
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| Contact Information |
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| Name:
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| Title:
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| Primary Number:
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| Secondary Number:
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| E-Mail:
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| Check Those That Apply:
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Owner
Occupant
Key Holder
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| Emergency Contact - Who can we contact if we can't reach the primary Contact? |
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| (EC) Name:
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| (EC) Title:
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| (EC) Primary Number:
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| (EC) Secondary Number:
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| (EC) Email:
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| (EC) Check Those That Apply:
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Owner
Occupant
Key Holder
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| Access & Site Information |
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| Special instruction to find the residence, i.e common driveway to stay to the left:
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| Gate Code:
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| Gate Access with Knox Key:
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Yes
No
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| Knox Box:
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Yes
No
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| Knox Box Location:
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| Hidden Key Location, Door Code or Garage Code:
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| Access concerns i.e, bridge, steep or narrow driveway or common driveway with multiple houses::
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| Building Information |
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| Building Name:
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| Physical Address:
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| Roof Type:
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Flat
Arched
Pitched
Hip
Dome
Shed
Other
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| Number of interior stairways to upper Floors:
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| Attic access from the interior?:
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Yes
No
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| Construction Type:
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Standard
Balloon
Light Weight - (Truss)
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| Concerns immediately around structure i.e. buried tanks, limited access, no turn around:
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| Is this a full time residence?:
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Yes
No
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| If not a full time residence, how often is it occupied?:
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| Average Number of Occupants at any one time:
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| Pets:
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Yes
No
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| Type of Pets:
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| Anyone in the structure that would require assistance to evacuate:
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Yes
No
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| If there are people that might need help getting out, where are they located:
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| Number of Stories:
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1
2
3
More
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| Is there a basement or crawl space?:
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Yes, Basement
Yes, Crawl Space
No Basement or Crawl Space
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| Building Length in Feet:
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| Building Width in Feet:
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| Basement Sq. Ft.:
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| 1st Floor Sq. Ft.:
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| 2nd Floor Sq. Ft.:
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| Attic Sq. Ft.:
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| Total Sq. Ft.:
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| Fire Fighting Water Supply |
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| Fire Hydrant?:
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Yes
No
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| If there is a hydrant, location of closest one?:
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| Water Storage Tank:
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Yes
No
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| If there is a water storage tank, location and capacity:
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| Dry Hydrant:
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Yes
No
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| If there is a dry hydrant, Location of the Dry Hydrant:
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| Pool Access:
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Yes
No
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| If Pool Access, is it indoor or outdoor and capacity? Available all year?:
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| Pond on property or near?:
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Yes
No
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| If there is a pond, can the FD get to it and any idea on how deep?:
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| Utility Service Information |
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| Propane :
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Yes
No
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| If you have Propane, location of tank including above ground or buried and also the capacity:
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| Heating Oil:
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Yes
No
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| If you have Heating Fuel, location of tank including above ground or buried and also the capacity:
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| Generator:
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Yes
No
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| If you have a Generator, is it propane or diesel and where is it located:
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| Solar Panels:
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Yes
No
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| Electrical Panel Location:
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| Elevator:
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Yes
No
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| Elevator brand:
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| Driveway Length:
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| Fire Protection Equipment |
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| Fire Alarm system: (If no, skip to Detector Types):
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Yes
No
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| Monitored System:
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Yes
No
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| Monitoring Company:
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| Monitoring Company Phone Number:
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| Main Control Box Location:
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| Detector Types:
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None
Smoke
Heat
Pull Station
CO
Combination Heads
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| Power Supply:
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None
Battery
Plug In
Hardwired with Battery
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| Carbon Monoxide Detector:
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Central Station
Plug In
Battery Operated
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| Does structure have a Sprinkler System:
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Yes
No
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| If so, what type of system:
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Wet
Dry
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| Do you have any of the following:
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Standpipe
Sprinkler Riser
Dry Chemical Extinguishing System
Foam Extinguishing System
Halon Extinguishing System
Ansul
Other
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| Hazard Material Storage |
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| Hazard materials present i.e. paints, thinner, propane bottles, gas containers, etc.: (If no, skip to Building Sketch):
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Yes
No
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| Safety Data Sheet Location, if any:
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| Hazard Materials Stored in Approved Cabinet?:
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Yes
No
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| Chemical Name, ID #, Max Quantity, Location/ Storage:
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| Other Information |
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| Use this are for pertinent information (Person on life support equipment or Oxygen dependent):
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| Building Sketch:
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| Entered Into RedNMX:
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| 34 VILLAGE GREEN, BEDFORD, NEW YORK 10506 |
