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Protecting our community with the highest level of professionalism Home Address: WAIVER, RELEASE AND HOLD HARMLESS AGREEMENT In consideration of the voluntary performance of a home fire safety inspection of my home located at , I, on behalf of myself, and all members of the family, as well as my heirs, executors, administrators or successors, hereby waive any claim or cause of action of any nature that I have or in the future may have, against any and all individuals or organizational participants in the Home Fire Safety Program, including but not limited to the Kalispell Fire Department, the municipality of Kalispell and its officers, agents or employees, which claim or cause of action grows out of results from a fire or other damage, following the said home fire safety inspection; and I further hereby agree to release and hold harmless any and all organizational and individual participants including aforesaid fire department and municipality in the Home Fire Safety Survey Program and against all damages of any kind, to persons or property, growing out of or resulting from a fire in my referenced home. I acknowledge having read, understood and agreed to the above waiver, and release. Print Name Signature Date Witness (print name) Signature Date This form generally indicates that the occupant or owner of the property agrees to waive his or her rights to sue any individual, any municipality and any other organizations or individuals involved in the fire safety inspection of this home, if a fire occurs after the inspection. The purpose of the waiver is to protect the individual or any organizations involved against liability arising from the home fire inspection. This statement is intended for information only, the terms of the waiver themselves shall prevail if there are any questions. You should seek advice if you do not understand this waiver. ---PAGE BREAK--- Protecting our community with the highest level of professionalism Basement ☐ Yes ☐ No Workshop area is clean of things that can burn. ☐ Yes ☐ No Hot water heater is set to no higher than 120° Fahrenheit. ☐ Yes ☐ No Things that can burn are at least 3 feet from the furnace. ☐ Yes ☐ No Furnace is inspected and cleaned annually. ☐ Yes ☐ No Chimney is inspected annually and cleaned as needed. ☐ Yes ☐ No Clothes dryer lint filter and vent pipe are clean. Garage ☐ Yes ☐ No There is a solid door between garage and residence. ☐ Yes ☐ No Gas powered equipment is stored in an outside shed or garage, separate from the home. ☐ Yes ☐ No Gasoline is stored in an approved safety container in an outside shed or garage, separate from the home. Outside the Home ☐ Yes ☐ No Outside electrical receptacles are GFCI and they are in good working condition. ☐ Yes ☐ No There is no rubbish, trash, brush, or tree trimmings accumulation on the property. ☐ Yes ☐ No Barbecue grill is only used outside and has a minimum of 10 feet of clearance from combustibles. Electrical ☐ Yes ☐ No AFCIs (arc-fault circuit interrupters) are installed throughout the home and they are working properly (new home construction only. ☐ Yes ☐ No Kitchen and bathrooms have GFCI outlets on countertop surfaces within 6 feet of running water outlets and they are working properly. ☐ Yes ☐ No All receptacles and switch faceplates are installed and in good condition. ☐ Yes ☐ No Receptacles have been tested and are in good working condition – no evidence of arcing or overheating. ☐ Yes ☐ No Lighting fixture canopies are fastened in place and fixture is in good condition. ☐ Yes ☐ No Bulbs in light fixtures are the correct wattage for the lighting fixture. ☐ Yes ☐ No Flexible cords and cables are not used as fixed wiring, run through holes in walls, ceiling or floor, run through doorways or windows or under carpets or attached to building surfaces. ☐ Yes ☐ No If there are children in the home, the home has tamper-resistant outlets. ☐ Yes ☐ No Electrical panels and distribution equipment is accessible for inspection and in good condition – no evidence of overheating, corrosion or other damage. Stair Safety ☐ Yes ☐ No Stair is provided with handrail. ☐ Yes ☐ No Stair can be illuminated for night time use. ☐ Yes ☐ No Stair tread depth and riser height are uniform. ☐ Yes ☐ No Stair landing nosing projections are consistent with other nosings on the stair flight. Kitchen ☐ Yes ☐ No Things that can burn are removed from the cooktop. ☐ Yes ☐ No Small appliances are unplugged when not in use. ☐ Yes ☐ No Adults stay in the kitchen when stovetop is in use. Living/Family Room ☐ Yes ☐ No Fireplace has proper screen and hearth. ☐ Yes ☐ No Things that can burn are at least 3 feet from space heaters and fireplaces. Bedrooms ☐ Yes ☐ No All bedrooms have two ways out – window and door. Continued on next page ---PAGE BREAK--- Protecting our community with the highest level of professionalism General ☐ Yes ☐ No Home has smoke alarm on every level. ☐ Yes ☐ No Home has smoke alarm in every bedroom. ☐ Yes ☐ No Smoke alarms are located outside each separate sleeping area. ☐ Yes ☐ No Smoke alarms are located at least 10 feet from a stationary or fixed cooking appliance. ☐ Yes ☐ No All smoke alarms are working. ☐ Yes ☐ No Family has a home fire escape plan. ☐ Yes ☐ No Family practices the home fire escape plan at least twice a year. ☐ Yes ☐ No House numbers are visible from the street day or night. ☐ Yes ☐ No Windows used for escape open easily – not blocked by furniture, security bars or nailed/painted shut. ☐ Yes ☐ No Home has carbon monoxide alarm outside each separate sleeping area. ☐ Yes ☐ No Home has carbon monoxide detector on every level. ☐ Yes ☐ No Carbon monoxide alarms are working. ☐ Yes ☐ No Smokers smoke outside the home. ☐ Yes ☐ No Large ashtrays are provided outside for smokers. ☐ Yes ☐ No Matches and lighters are stored in a secure cabinet or in a safe area. ☐ Yes ☐ No Lit candles are not left unattended. ☐ Yes ☐ No Flammable liquids, if stored in the home, are limited in quantity. ☐ Yes ☐ No The home is not cluttered with clothes, magazines, newspaper and other items that can burn. With your consent, the Home Fire Safety Survey Team has done a fire inspection of your home. The items checked NO may put you and your family at risk. You are urged to correct these for your own safety. This inspection does not identify future conditions such as failure of components, wiring or human behavior which could result in a fire. ---PAGE BREAK--- Protecting our community with the highest level of professionalism S – Smoke Alarm X – Way Out M – Meeting area