FPS32

PORT COQUITLAM FIRE & EMERGENCY SERVICES

SMOKE ALARM INSPECTION REQUEST

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Occupant Name:

Address: Unit #:

City, Prov: Port Coquitlam, BC Postal Code:

Home Phone #: Cell Phone #:

Name of Requestor (if different than Occupant):

Name of Property Owner (if different than Occupant):

Preferred Inspection Date:

Preferred Day of Week:

Preferred Time of Day:

How many people are living at this residence?

Are there any children in the household? Yes No Ages:

Are there any seniors in the household? Yes No

ID WITH CONFIRMATION OF ADDRESS WILL BE REQUIRED PRIOR TO INSPECTION BEING CONDUCTED.

Questions? Please call (604) 927-5288

Completed forms can be sent via:

Email: fire@portcoquitlam.ca

Fax: (604) 927-5406

Mail or drop off: Port Coquitlam Fire & Emergency Services 1725 Broadway Street Port Coquitlam, BC V3C 2M9 ATTN: Fire Protective Services

Or by clicking the submit button:

(For office use only) CHECKLIST FOR PUBLIC EDUCATION OFFICER:

Event scheduled with:

Event approved: Event denied: Requester contacted:

Comments:

Special instructions:

Submit

FPS32A PORT COQUITLAM FIRE & EMERGENCY SERVICES

SMOKE ALARM INSPECTION WAIVER AND RELEASE

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PLEASE READ THIS INFORMATION CAREFULLY

Port Coquitlam Fire & Emergency Services is providing me a smoke alarm and/or batteries through its Smoke Alarm Inspection program without cost to me. I understand and agree that I alone am responsible for the maintenance of my smoke alarm in accordance with the manufacturer’s instructions. Maintenance includes, but is not limited to, testing the smoke alarm monthly and buying and installing new batteries at least once a year to make sure the smoke alarm continues to operate. I understand that the smoke alarm will function only with a charged battery and that the battery will discharge over time. I also understand that smoke alarms and batteries are subject to defect and the City of Port Coquitlam does not make any warranties or representations about the performance of the smoke alarm, the batteries, or any other equipment, product, or service provided to me under this program. The City of Port Coquitlam specifically disclaims any warranty (express or implied) that a smoke alarm, battery or equipment or product provided under this program is fit for a particular purpose and disclaims any warranty of merchantability (express or implied). Further, the City of Port Coquitlam makes no warranties or representations about the services provided through this program, including the proper installation of the smoke alarm, the proper location of the installation of equipment or products, the proper or correct or timely replacement of batteries or smoke alarm, testing, or the availability of City personnel to perform or assist in the performance of such services. Further, this program may be discontinued at any time without notice. In consideration of the acceptance of a smoke alarm, batteries, and or equipment, products, or services, I hereby hold City of Port Coquitlam harmless and waive, release, and discharge any and all claims for death, personal injury, or property damage which I may have, or which may occur or accrue to me, against the City of Port Coquitlam, its officers, officials, employees, and volunteers, and any other involved municipal or public agencies from and against any and all liability arising out of or connected in any way with the Smoke Alarm Inspection program or my acceptance of said smoke alarm, batteries, equipment, products, or services. It is further understood and agreed that this waiver and release is binding upon my guests, invitees, family members, heirs and assigns. The personal information on this form is collected under the authority of the Port Coquitlam Fire & Emergency Services Bylaw, the Fire Services Act, and the Community Charter and will be used only for the purpose for which it was collected or for a use consistent with that purpose.

Name: Date:

Address: Phone #:

Age group (circle all that apply: Children Adults Seniors

Signature:

# of detectors installed Location(s):

HALL SHIFT EMPLOYEE #

FPS32B PORT COQUITLAM FIRE & EMERGENCY SERVICES

SMOKE ALARM MAINTENANCE CHECKLIST

Address/Suite Number: Date:

A. ROUTINE TEST AND MAINTENANCE YES NO

1. Smoke alarm is securely fastened to the wall or ceiling

2. Smoke alarm shows no evidence of physical damage, paint application or excessive grease and dirt accumulations.

3. Ventilation holes on the smoke alarm are clean and free of obstructions

4. Smoke alarm signal sounds when the test device is operated

B. ANNUAL TEST AND MAINTENANCE YES NO

1. Smoke alarm is securely fastened to the wall or ceiling

2. Smoke alarm shows no evidence of physical damage, paint application or excessive grease and dirt accumulations.

3. Smoke alarm has been vacuumed

4. Smoke alarm is powered by: AC wiring Standard Battery Long life battery that expires in the

year: __________________________

For battery operated smoke alarms: Battery has been replaced and securely connected to the clips Battery is of the type _______________ as recommended by the manufacturer

Battery terminals are free of corrosion and signs of leakage

5. Smoke alarm signal sounds when the smoke alarm is tested using smoke produced from incense stick; canned smoke

C. SERVING AND REPLACEMENT (complete this section if “NO” is checked in section A or B)

1. Smoke alarm has been serviced as follows:

Smoke alarm has been replaced as a result of: Failure to sound alarm during test Frequent false alarms Physical damage Battery leakage Painted exterior case Age Excessive stains, grease or dirt accumulations Other: _______________

Comments

Captain’s Signature: