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The Std 850 form is a crucial document for fire safety inspections in California. It serves as a formal request for a thorough evaluation of a facility's compliance with fire safety regulations. This form includes essential sections where agencies need to provide specific information, such as the agency contact's details, the requesting agency's facility number, and the purpose of the inspection—whether it is an original request, renewal, or a change in capacity or ownership. Facility owners must also specify the type of residents their facility accommodates. Options for occupancy include ambulatory, nonambulatory, and bedridden populations. Additionally, the form captures information about the facility's address, the number of buildings, and any special conditions that may apply. Upon completion, the fire authority will review the request and indicate whether fire clearance has been granted or denied, along with specific codes. Ultimately, the Std 850 form helps ensure that fire safety inspections are organized and standardized across different facilities, while providing a clear record that is vital for maintaining compliance with state regulations.

Std 850 Example

STATE OF CALIFORNIA

FORESTRY AND FIRE PROTECTION

 

 

 

 

 

Clear

 

 

Print

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRE SAFETY INSPECTION REQUEST

 

 

 

 

See instructions on reverse.

 

STD. 850 (REV. 4-2000)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENCY CONTACT'S NAME

 

TELEPHONE NUMBER

 

 

 

REQUEST DATE

 

PROGRAM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EVALUATOR'S NAME

 

 

 

REQUESTING AGENCY FACILITY NUMBER

 

REQUEST CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CODES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

ORIGINAL

A. FIRE CLEARANCE

LICENSING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

RENEWAL

B. LIFE SAFETY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENCY

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

CAPACITY CHANGE

NAME AND

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

OWNERSHIP CHANGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

ADDRESS CHANGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

NAME CHANGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AMBULATORY

NONAMBULATORY

 

BEDRIDDEN

 

 

 

TOTAL CAPACITY

CAPACITY

 

PREVIOUS CAPACITY

CAPACITY

PREVIOUS CAPACITY

CAPACITY

 

 

PREVIOUS CAPACITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FACILITY NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

LICENSE CATEGORY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS (Actual Location)

 

 

 

 

 

 

 

 

 

 

 

NUMBER OF BUILDINGS

CITY

RESTRAINT

FACILITY CONTACT PERSON'S NAME

FACILITY CONTACT PERSON'S TELEPHONE NUMBER

HOURS

SPECIAL CONDITIONS

TO BE COMPLETED BY INSPECTING AUTHORITY

CLEARANCE /DENIAL CODE

 

 

 

 

 

 

 

 

 

 

CODES

FIRE

 

 

 

 

 

 

1.

FIRE CLEARANCE GRANTED

AUTHORITY

 

 

 

 

 

 

2.

FIRE CLEARANCE DENIED

NAME AND

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

A. EXITS

 

 

 

 

 

 

 

 

 

 

B. CONSTRUCTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. FIRE ALARM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D. SPRINKLERS

INSPECTOR'S NAME (Typed or Printed)

TELEPHONE NUMBER

 

 

CFIRS NUMBER

OCCUPANCY CLASS

 

 

 

 

 

 

 

 

 

 

 

 

 

E. HOUSEKEEPING

 

 

 

 

 

 

 

 

 

 

F. SPECIAL HAZARD

 

 

 

 

 

 

 

 

 

 

 

INSPECTION DATE

 

INSPECTOR'S SIGNATURE (Typed or Printed)

 

 

 

 

 

 

G. OTHER

EXPLAIN DENIAL OR LIST SPECIALCONDITIONS

This form is designed for use with a window envelope
Licensing or Requesting Agencies--Complete the following 19 sections on this form
before submitting it to the fire authority having jurisdiction.
INSTRUCTIONS

STATE OF CALIFORNIA FORESTRY AND FIRE PROTECTION

FIRE SAFETY INSPECTION REQUEST

STD. 850 (REV. 4-2000) (REVERSE)

1. AGENCY CONTACT, 2. TELEPHONE NUMBER,

5. EVALUATOR.Enter the name and telephone number of agency contact person.

3.PROGRAM. Licensing agency use.

4.REQUEST DATE. Enter date request was prepared.

6.REQUESTING AGENCY FACILITY NUMBER. This is the file number assigned by the licensing agency.

7.REQUEST CODE. Use the seven codes shown and insert the appropriate number in the box following "Request Code". If NAME CHANGE, please list previous name. Insert date of original request is other than an original.

8.AGENCY NAME AND ADDRESS. Enter the name and address of the licensing facility requesting the inspection.

9.AMBULATORY--NONAMBULATORY--BEDRIDDEN.

Capacity:

Insert in the appropriate section, the capacity

 

of licensed ambulatory or nonambulatory oc-

 

cupants covered by this request.

Previous

If request is for renewal or capacity change,

Capacity:

insert capacity of previous clearance.

Total

Show total licensed capacity. If the facility is

Capacity:

intended to house part ambulatory, nonambu-

 

latory, and part bedridden, show the total of

 

the three types of occupants.

10.FACILITY NAME. Insert the name of the facility as it will appear on the license. List identifying sub name if known (i.e., Hacienda Corp/Medina Lodge).

11.LICENSE CATEGORY. Insert the category of license being sought as it will appear on the license certificate.

12.ADDRESS. Insert street address and city only. A post office box is not acceptable as only location.

13.NUMBER OF BUILDINGS. Insert the total number of buildings to be used for housing of the occupants covered by the license.

14.RESTRAINT. Indicate if physical restraint (locked in a room or the building) is to be used in the housing of the occupants.

15.FACILITY CONTACT PERSON--TELEPHONE NUMBER. Indicate the name and telephone number of the responsible individual at the facility to be contacted by the fire authority.

16.HOURS. Indicate the number of hours the occupants are housed at the facility (less than 24 or 24+).

17. SPECIAL CONDITIONS. Indicate any conditions

unique to this request. As an example, if the inspection request is for one building in a multi-building facility.

FIRE AUTHORITY CONDUCTING THE INSPECTION--COMPLETE THE FOLLOWING:

18.FIRE AUTHORITY, NAME AND ADDRESS. Insert the name and address of the fire authority where the facility is located.

19.CLEARANCE/DENIAL CODE. Use the two codes: 1 for clearance granted, and 2 for clearance denied. If denied, also include the appropriate letter code. As an example, Denial based upon exiting would be coded 2A.

20.INSPECTOR'S NAME. Print the initial of the inspector's first name and full last name; insert the telephone number where the inspector may be contacted.

21.CFIRS I.D. NUMBER. Insert the fire department's number assigned by California Fire Incident Reporting System.

22.OCCUPANCY CLASSIFICATION. Use California Building Code occupancy classifications and insert the occupancy determined by the inspector.

23.INSPECTION DATE. Enter the actual date of the in- spection.

24. INSPECTOR'S SIGNATURE. To be signed by the inspector conducting the inspection.

25.EXPLAIN DENIALOR SPECIAL CONDITIONS. If clearance code #2 is used, briefly explain reason. This space is also to be used to specify any additional limitations placed by the fire authority, such as the use of certain floors or sleeping rooms approved for nonambulatory clients.

Form Characteristics

Fact Name Description
Form Title The STD 850 form is officially titled "Fire Safety Inspection Request."
State This form is specific to the State of California.
Governing Law It is governed under California Code of Regulations, Title 19.
Revision Date The current version of the form was revised in April 2000.
Purpose The form is used to request a fire safety inspection for various types of facilities.
Types of Requests Possible requests include original, renewal, capacity change, and ownership change.
Facility Information Facility details such as name, address, and contact information must be provided.
Inspection Codes The form includes codes to indicate whether fire clearance has been granted or denied.
Inspector Requirements An inspector must sign and provide details about the inspection, including clearance status.

Guidelines on Utilizing Std 850

Successfully completing the STD 850 form requires careful attention to detail and accurate information. Once the form is filled out, it should be submitted to the appropriate fire authority for consideration. Each section has specific requirements and should be filled out in the order presented to avoid omissions.

  1. Enter the Agency Contact's Name: Fill in the name of the main contact at your agency.
  2. Provide Telephone Number: Include the contact number for the agency representative.
  3. Request Date: Write the date when the request is prepared.
  4. Insert Requesting Agency Facility Number: This is a unique file number assigned by the licensing agency.
  5. Enter Request Code: Use one of the seven codes provided to identify the type of request.
  6. Agency Name and Address: Provide the full name and address of the licensing facility making the request.
  7. Fill in Capacity Details: Indicate the capacity for ambulatory, nonambulatory, and bedridden occupants. Also, specify previous capacity if applicable.
  8. Facility Name: Enter the official name of the facility as it will appear on the license.
  9. License Category: Indicate the category of license being sought.
  10. Street Address: Write the actual street address and city, avoiding P.O. box listings.
  11. Number of Buildings: Enter the total number of buildings associated with the facility.
  12. Indicate Restraint Use: Specify whether physical restraint will be employed.
  13. Facility Contact Person's Name and Telephone Number: Include the name and phone number of the responsible contact at the facility.
  14. Hours: State the housing hours for occupants as less than 24 or 24+ hours.
  15. Special Conditions: Note any unique circumstances associated with this inspection request.
  16. Fire Authority Name and Address: Provide the name and address of the fire authority conducting the inspection.
  17. Clearance/Denial Code: Mark whether clearance is granted or denied, using the corresponding codes.
  18. Inspector's Name: Print the inspector's name and the contact number for follow-up.
  19. Insert CFIRS I.D. Number: Include this unique identifier for the fire department.
  20. Occupancy Classification: Use California Building Code classifications to describe occupancy.
  21. Inspection Date: Fill in the actual date the inspection occurs.
  22. Inspector's Signature: The inspecting official must sign in this section.
  23. Explain Denial or Special Conditions: If a clearance is denied, briefly explain the reason and any conditions imposed.

What You Should Know About This Form

What is the purpose of the STD 850 form?

The STD 850 form is a Fire Safety Inspection Request. It is designed for licensed facilities in California to request a fire safety inspection from the local fire authority. This form helps ensure that facilities meet necessary safety standards to protect occupants from fire hazards.

Who should fill out the STD 850 form?

The form should be completed by the requesting agency or facility. This includes details such as the agency name, contact person, and the specific type of request being made. It's essential for the responsible individual at the facility to provide accurate information to facilitate the inspection process.

What types of requests can be made using the STD 850 form?

The form allows for various types of requests: original inspection, renewal, capacity changes, ownership changes, address changes, name changes, and other requests. Each request type has specific codes that need to be filled out on the form to indicate the purpose of the inspection.

What information is required on the STD 850 form?

The form requires several key pieces of information, including the facility name and address, total capacity, number of buildings, type of occupancy, and details about any special conditions. This information is crucial for the fire authority to conduct a thorough inspection.

What happens after the STD 850 form is submitted?

Once submitted, the local fire authority will review the request and schedule an inspection. After conducting the inspection, they will fill out the clearance or denial code based on the findings. You will then receive notification of the outcome, including any special conditions if the request is denied.

What should I do if my request is denied?

If your request is denied, the form provides space for the inspector to explain the reasons behind the denial. It's important to review this explanation carefully. Depending on the issues identified, you may need to address the concerns before resubmitting your request for inspection.

How often should I submit an STD 850 form?

The frequency of submitting this form varies based on changes in your facility. An original request is needed for new facilities, while renewals are typically required every few years. Additionally, any substantial alterations to occupancy or operations might necessitate submitting this form again to ensure compliance with fire safety regulations.

Common mistakes

Filling out the STD 850 form accurately is crucial for a smooth inspection process. However, common mistakes often hinder this. One frequent error is neglecting to provide the request date. This date is essential as it marks when the request was prepared. Without it, the fire authority may struggle to prioritize and track requests efficiently.

Another mistake involves incorrect entry or omission of the requesting agency facility number. This unique identifier is crucial because it connects your request to the licensing agency’s records. If this number is missing, it could delay processing and lead to confusion.

A significant oversight is failing to include the facility contact’s telephone number. This detail is necessary for timely communication between the fire authority and the facility. The absence of this information might result in prolonged wait times or missed vital updates during the inspection process.

Many individuals also mistakenly provide a post office box address instead of a physical location. The form specifically mandates that only a street address should be provided. Submitting a P.O. box could lead to issues in sending official correspondences and complicating the inspection logistics.

Errors in the capacity section are another common pitfall. Applicants need to accurately indicate the total licensed capacity and differentiate between ambulatory, nonambulatory, and bedridden occupants. Confusing or incorrect figures can raise red flags during the evaluation.

Some people overlook specifying special conditions unique to their request. This information can aid inspectors in understanding the context of the facility’s needs and facilitate a smoother inspection. Failing to communicate these can result in misunderstandings or additional challenges later on.

Inaccurately selecting the clearance/denial code is also critical. Applicants should ensure they are using the correct codes provided in the instructions. A mistake here could lead to the wrong assumptions being made about the facility’s compliance status.

Finally, one of the most significant errors is the lack of the inspector's signature on the form after the inspection. This signature confirms that the inspection has taken place and that the information recorded is valid. Omitting this could invalidate the form entirely.

By being aware of these common mistakes and taking care to avoid them, individuals can significantly enhance the efficiency of their inspection process.

Documents used along the form

The STD 850 form is a crucial document for fire safety inspection requests in California. To ensure a comprehensive submission and adherence to fire safety regulations, several other documents are often used in conjunction with the STD 850. Here is a list of commonly associated forms and their descriptions.

  • Fire Clearance Application: This document serves as a formal request for fire clearance prior to the operation of a facility. It contains essential details about the facility, including its capacity and specific configurations.
  • Risk Assessment Form: This form assists in identifying potential hazards within the facility. It evaluates risks related to fire safety and helps in creating strategies to mitigate them.
  • Inspection Checklist: Used by inspectors, this checklist outlines required safety features and conditions that must be reviewed during the inspection process to ensure compliance with safety standards.
  • Emergency Action Plan: A mandated document that describes procedures for evacuation, alerting emergency services, and ensuring resident safety during a fire or emergency situation.
  • Facility Licensing Application: This form is necessary to obtain a license to operate a care facility. It requires information on the facility’s compliance with fire safety regulations and other essential requirements.
  • Owner/Operator Affidavit: This affidavit ensures that the owner or operator of the facility acknowledges their responsibilities regarding compliance with fire safety laws and regulations.
  • Special Conditions Addendum: If there are unique conditions associated with a facility that require attention, this addendum provides detailed explanations and specifications relevant to the inspection or operation.

Utilizing the STD 850 form alongside these additional documents helps to streamline the inspection process and enhances compliance with fire safety regulations. Being organized ensures that all necessary information is readily available for the authorities conducting the review.

Similar forms

The STD 850 form, used for fire safety inspection requests in California, shares similarities with several other important documents. Here are four documents that resemble the STD 850 in terms of purpose and content:

  • Building Permit Application: Like the STD 850 form, this application is essential for ensuring that structures comply with safety regulations. Both documents require detailed information about the facility, including the location and intended occupancy.
  • Fire Code Compliance Report: This report also relates to fire safety, outlining whether a facility meets local fire codes. Similar to the STD 850, it includes specific details about fire alarms, exits, and overall safety measures.
  • Occupancy Permit Request: This request is mandatory for facilities to legally operate. Much like the STD 850, it addresses the capacity and classification of occupants, which helps to ensure safe use of the space.
  • Health and Safety Inspection Form: This form is utilized for evaluating health and safety compliance in various facilities. It mirrors the STD 850 in terms of collecting vital data on conditions that impact the safety of residents and staff alike.

Dos and Don'ts

When filling out the STD 850 form, it is important to ensure accuracy and completeness. Here are some dos and don’ts to consider:

  • DO enter the agency contact's name and telephone number clearly.
  • DO double-check the request date before submission.
  • DO indicate the capacity of occupants accurately according to the form’s sections.
  • DO include the full address of your facility without using a post office box.
  • DON'T forget to include special conditions that may affect the inspection.
  • DON'T leave any sections blank unless instructed; every detail matters.
  • DON'T use informal language; maintain a professional tone throughout.
  • DON'T forget to have the inspector sign the form after completing their assessments.

Misconceptions

Misconceptions about the STD 850 form can lead to confusion regarding its purpose and the procedures associated with it. The following list clarifies seven common misunderstandings:

  • The STD 850 form is only for new facility requests. This form is used for various purposes, including renewals, capacity changes, and ownership changes. Its multifunctional nature means it is relevant to both new and existing facilities.
  • Only governmental agencies can request inspections using this form. While mainly used by licensing agencies, any agency that meets the criteria can submit the form for a fire safety inspection request.
  • The form guarantees fire clearance approval. Submitting the STD 850 form does not ensure that fire clearance will be granted. The inspecting authority will determine clearance based on the conditions outlined during the inspection.
  • All facilities require the same type of information. The information required varies depending on the specific type of facility. Different codes apply to different requests, necessitating tailored information.
  • Only the facility owner can submit the STD 850 form. An authorized representative may complete and submit the form on behalf of the facility owner, providing that they have proper authority to do so.
  • Once submitted, the request cannot be modified. It is possible to update the request if circumstances change or inaccuracies are discovered prior to the inspection occurring.
  • The inspection date must be specified when submitting the form. While providing the inspection date is helpful, it is not a mandatory requirement at the submission stage; it can be confirmed later.

Understanding the true functions and requirements of the STD 850 form is crucial for ensuring compliance and facilitating smoother operational processes in facility management.

Key takeaways

When filling out and using the Std 850 form for fire safety inspections in California, consider the following key takeaways:

  • Complete All Sections: Ensure that all 19 sections of the form are filled out accurately before submission. This includes providing details like contact information, facility capacity, and special conditions.
  • Understand Request Codes: Familiarize yourself with the seven request codes and use them appropriately. Proper coding helps categorize the type of inspection request being made.
  • Provide Accurate Capacity Information: Clearly indicate the facility's total capacity, distinguishing between ambulatory, nonambulatory, and bedridden occupants. Include previous capacities if applicable.
  • Specify Special Conditions: If there are unique aspects of your request, include them in the special conditions section. This helps the fire authority understand any specific circumstances surrounding the inspection.
  • Confirm Fire Authority Details: Include the name and address of the fire authority conducting the inspection. This ensures that the form is routed properly for review.
  • Review for Completeness Before Submission: Double-check the form for any errors or omissions. A thorough review can prevent delays and complications in the inspection process.