CERTIFICATION

FIRE SAFETY MAINTENANCE REPORT

This is to certify that all fire safety issues are addressed and that all
required fire safety systems are installed and maintained as prescribed in
the RA 9514 and its RIRR and other applicable laws of the
____________________________________________________________
____________________________________________________________
____________________________________________________________

Attached herewith the updated record of regular inspection, scheduled

testing and commissioning, and regular preventive maintenance record to
ensure proper operational condition of all firefighting equipment and fire
detection devices.

___________________________ _______________________
Building Administrator/Owner Third Party / Safety Officer
(signature over printed name) (signature over printed name)

Contact Number: _________________ Contact Number: _________________

Date : ______________ Date : ______________

If signed by a third party consultant

specializing in said installation:

Name of Company: _______________

Address: ________________________
 FIRE SAFETY MAINTENANCE REPORT

1. Short Description of the Building/facility.

Name of the Establishment:

Type of occupancy:
Type/Content of Product:
Owner:
Location:
Area per Floor
Total Floor Area:
No. of Storey:
Portion Occupied:
Lessor ( ) Lessee ( )

2. Statement of testing and maintenance standard used.

The undersigned perform actual inspection, checking, review, and testing of all
fire protection equipment and all fire safety issues are addressed based of RA 9514 and
NFPA standards.

3. Discussions of Fire Protection and Life Safety Measures

EXIT AND EGRESS

No. of exits __________with self-closing device [ ] Yes [ ] No

Door Swing in the direction of exit [ ] Yes [ ] No Location __________
Type of doors ________________
Enclosed [ ] Yes [ ] No Location _____________________
Obstructed [ ] Yes [ ] No

Remarks: The means of egress are sufficient for the occupants of a building to evacuate
safely in case of an emergency.

FIRE SUPPRESSION

Type: [ ] STANDPIPE SYSTEM [ ] AUTOMATIC FIRE SUPPRESSION SYSTEM

(SPRINKLER SYSTEM) [ ] Both
[ ] Wet [ ] Dry
 Tank Capacity ________________ Location_______________

Fire Pump:
Type: _____________
Pump Rating:
____ GPM ____ PSI ____ HP ____ RPM ____ VAC

Pump Drive: [ ] Electric, KVA: ____ [ ] Diesel Engine, Fuel Tank Cap: _____
Operating Discharge Time: ________
Fire Pump suction size: _____ in, Discharge size: _____ in.
Transfer Switch: [ ] yes [ ] No
Transfer Switch rating: _____ Hp, _____ VAC
Fire Pump Cut-in Pressure: ______ PSI, Cut-out: ______ PSI

Jockey Pump:
Type: _____________
Pump Rating:
____ GPM ____ PSI ____ HP ____ RPM ____ VAC

Pump Drive: [ ] Electric, KVA: _____ [ ] Diesel Engine, Fuel Tank Cap: _____
Jockey Pump suction size: _____ in, Discharge size: _____ in.
Jockey Pump Maintaining Pressure: ______ PSI
Jockey Pump Cut-in Pressure: ______ PSI, Cut-out: ______ PSI

System Accessories:
Siamese Intake Provided:
[ ] Yes [ ] No Location _____________
Size _____________ No. of Units ______________
Accessible [ ] Yes [ ] No

Fire Hose Cabinets Provided [ ] Yes [ ] No

With Complete accessories [ ] Yes [ ] No
Location _____________
No. of Units per Floor ____ Size of Hose____
Length of Hose _____________________
Type of Nozzle_______ Date Last Tested _____________
Fire Lane Provided: [ ] Yes [ ] No Location of nearest Fire Hydrant
Location of Fire Department Connection: ______________________________
Type of Sprinkler Heads Installed__________________________
No. of Sprinkler Heads per Floor _______________Total_______________
Spacing of Heads___________
Date Last Tested ___________

Provided with Tamper Switch: Yes [ ] No [ ] others: ___________

Provided with Flow Switch/Water Flow Detector: Yes [ ] No [ ]
Provided with OS&Y Valve: Yes [ ] No [ ]

REMARKS: The automatic fire suppression system is in good condition, sufficient and
functional.

FIRST AID FIRE PROTECTION EQUIPMENT (PORTABLE FIRE EXTINGUISHERS)

Type___________ Capacity _______ No. of Units__________

Properly Maintained [ ] Yes [ ] No Conspicuously Located [ ] Yes [ ] No
Accessible [ ] Yes [ ] No
Other Types Provided, if any __________________

REMARKS: All portable fire extinguishers are in good condition, sufficient and
functional.

C. FIRE DETECTION, ALARM COMMINICATION AND EVALUATION SYSTEM

Fire Alarm Provided [ ] Yes [ ] No Type: [ ] Manual [ ] Automatic Centralized [

] Yes [ ] No
Location of Fire Alarm Control Panel ___________________________________
No. of Bells per Floor_______ Location__________________________
Monitored [ ] Yes [ ] No
No. of Pull Stations per Floor __________________
Smoke Detectors [ ] Yes [ ] No
No. of Units per Room _______ Integrated [ ] Yes [ ] No
Heat Detectors [ ] Yes [ ] No No. of Units per Room ______
Integrated [ ] Yes [ ] No
Others: ________
No. of Units per Room _______ Integrated [ ] Yes [ ] No
Power Source of Detectors: [ ] AC [ ] DC
If auto, back-up with DC [ ] YES [ ] NO
Total Detectors per Floor_______________
Date Last Tested ________________

REMARKS: All fire alarm system are in good condition, serviceable, sufficient and
functional.

D. SMOKE CONTROL MANAGEMENT (IF APPLICABLE)

STAIRWELL PRESSURIZATION

No. of Floors:________________
Stairwell Pressurization:________
Elevator Pressurization:_________
Firefighter’s smoke control panel:______________
Location:______________
Activation of Smoke Control System:_____Automatic_____Manual
Type of Injection System:___________
No. of Blower/Fan:___________
Area of Safe Refuge:_____________
Motorized Smoke/fire Damper:___________ Travel Time_____Sec
Automatic Air Release Vent:_______________
Elevator Shaft smoke Detector:____________
Make-up Air Blower:_________________
Elevator Recall:_______________
Fireman’s Switch:________________
Automatic Door Closer:___________
Exit Door Re-entry:_____________
Panic Hardware:____________
Centrifugal Fan/Blower Blade Type:_______________
Air flow Rate:____________CFM,at Operating Time______Sec
Static Pressure:____________Pa
Rated Power:_________ Hp
Blower wheel Diameter:__________Inches
Rotating Speed:_______RPM
Direct/Coupling Drive:________Belt Drive________
Transfer Switch:_________
Stand By Power:________Hp_______KVA
Smoke Control system Integrated with Fire Alarm:________
HVAC System Control:_____________
Automatic Fire Department notification:___________

Remarks: Stairwell pressurization is in good condition, sufficient and functional.

SMOKE EXTRACTOR

No. of Floors:________________
Firefighter’s smoke control panel:______________
Location:______________
Activation of Smoke Control System : _____Automatic _____ Manual
Type smoke Detector:________
Response Time of Activation:________ Sec
No. of Blower/Fan:___________
Location:____________
Motorized Smoke/fire Damper :__________Travel Time _____Sec.
Make-up Air Blower:_________________
Centrifugal Fan/Blower Blade Type:_______________
Air flow Rate :____________CFM, at Operating Time ______Sec.
Static Pressure :____________Pa.
Rated Power:_________ Hp
Blower wheel Diameter :__________Inches.
Rotating Speed :_______RPM.
Direct/Coupling Drive: ________ Belt Drive:________
Transfer Switch:_________
Stand By Power :_________HP. ______ KVA
Smoke Control system Integrated with Fire Alarm:________

Remarks: Smoke extractor is in good condition, servcieable, sufficient and functional.

E. EMERGENCY POWER SUPPLY

B. Generator Set Provided [ ] Yes [ ] No [ ] Automatic [ ] Manual

Fuel: [ ] Diesel [ ] Gasoline
Capacity ___________________ Location_________________________
Dikes/Bund wall Provided [ ] Yes [ ] No
Container: [ ] Above-ground [ ] Underground
Dispensing System [ ] By pump [ ] By gravity
Output Capacity___________ kva
Type of phase: _________

Remarks: Generator Set is in good condition, sufficient and functional.

F. OTHER TESTING AND MAINTENANCE RECORDS, INCLUDING TEST RESULTS

OF THE ELEVATOR RECALL SYSTEM

Mechanical System
Is there any mechanical hazard [ ] Yes [ ] No
Specify location___________________________________________
No. of elevators
provided___________________________________________________
Elevators floor ____________
Fireman's elevator provided [ ] Yes [ ] No

Fireman's key/switch provided [ ] Yes [ ] No

Remarks: Mechanical system is in good condition, sufficient and functional.

G. OTHER APPLICABLE SYSTEM

OVERALL REMARKS: ALL FIRE PROTECTION EQUIPMENT AND SYSTEM ARE IN

PLACED, SUFFICIENT, IN GOOD CONDITION, AND FUNCTIONAL AND CAN BE
RELIED UPON IN CASE OF AN EMERGENCY.

___________________________ _______________________
Building Administrator/Owner Third Party / Safety Officer
(signature over printed name) (signature over printed name)

Contact Number: _________________ Contact Number: _________________

Date : ______________ Date : ______________
Designation:______________________
PRC ID number (if applicable):___________
If signed by a third party consultant
specializing in said installation:

Name of Company: _______________

________________________________
Address: ________________________