Supplemental Building Questionaire
Date: 
Please complete a separate questionaire for each building over 25 years old.
 
Applicant: 
Location No.:  Producer: 
Address: 
 
City, State, Zip:    
 
  YES NO  
Has the entire electrical/wiring system been updated? If Yes, When and How?
Complete overload protection by circuit breakers? If no, please explain:
Has the entire plumbing system been updated? If Yes, When and How?
Potable water system using copper and/or PVC piping? If no, please explain:
Age of Hot Water System? Type (gas, electric, or steam; central or individual)
 
Has the entire heating system been updated? If Yes, When and How?
Age of Heating System? Type (gas, electric, or steam; central or individual)
 
When was the roof last replaced? Type of Roof:
 
Please answer each question. Explain all answers marked with an asterisk in detail on a separate sheet.
  YES NO
Are there any unprotected vertical openings (stairways, laundry/trash chutes)?  *
 
Are all fire doors rated for one hour protection?  *
 
Are the concealed spaces or attic used for storage?  *
 
Are there any fire/draft stops in concealed space or attic?  *
 
Are the surrounding buildings in good condition and maintenance?  *
 
Was the building built for its present type of occupancy?  *
 
 
 
Applicant Signature:__________________________________________________     Date: ___________
 
 
 
Producer Signature:__________________________________________________     Date: ___________

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