Fire Barrier INSP Form

FIRE BARRIER INSPECTION FORM

FACILITY:

FLOOR:

INSPECTOR:

DATE:

BUILDING:

LOCATION/STAIRWELL:

SIGNATURE:

BARRIER COMPLIANT

REPAIRED

⃝ YES
⃝ YES

⃝ NO
⃝ NO

(IF NOT COMPLIANT FILL OUT DESCRIPTION ON BACK)

FREFFIRE BARRIER INSPECTION CHECKLIST

PASS

FAIL

N/A

⃝

⃝

⃝

Visual confirmation that fire barrier is present.

⃝

⃝

⃝

Adjoining rooms have visible fire barrier.

⃝

⃝

⃝

Identified fire barrier has no PRIMARY penetrations.

⃝

⃝

⃝

Adjoining room(s) has no PRIMARY penetrations
ID:

⃝

⃝

⃝

Identified fire barrier has no SECONDARY penetrations.

⃝

⃝

⃝

Adjoining room(s) has no SECONDARY penetrations

NOTE:

Hard Ceilings with access panels, allow visible confirmation, may limit capability of making repairs.
Primary Penetrations: Holes, Cracks, or Chipping that
prevents the Fire Barrier from being 100% complete.
Secondary Penetrations: Utility stub outs that are not
capped off.

ID:

FIRE BARRIER/DOOR PM’S INSPECTION NOTES

DESCRIPTION OF FAILURES:

REPAIRS MADE:

DATE REPAIRS WERE COMPLETED:

REPAIRS COMPLETED BY:

ONCE COMPLETED

ALL INSPECTION FORMS MUST BE

RETURNED TO

CARPENTER SHOP SUPERVISOR

FOR VERIFICATION AND UPLOAD