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2. Property Information
4. Address 1 *
6. Address 2
8. City*
9. State*
10. Zip Code*
12. APN (Optional)

    If available, please provide site's APN. 

14. Number of Dwellings*
    -- Select One --12345678910+

    Select number of dwellings at property.

16. Owner/ Responsible Party Information
18. First Name*
19. Last Name*
21. Company Name (Optional)

    If applicable, please provide.

23. Mailing Address*
25. Phone Number*
26. Email Address*
28. Property Owner/Agent - Please select from dropdown.*
    -- Select One --I am the property ownerI am the authorized agent for the owner (Written authorization on file)
30. Certification Statement

    I hereby certify the following regarding the above-referenced Group R-2 Occupancy: 

    1. Portable fire extinguishers are provided within each individual dwelling unit at this property. 

    2. Each fire extinguisher is listed and approved, readily accessible, properly charged, operable and maintained in accordance with California Fire Code (CFC) §906.

    3. The fire extinguishers provided are not obstructed or removed and are intended for tenant use. 

    4. I understand that submission of this certification does not limit the Fire Department's right to inspect the property for verification or enforcement purposes. 

    5. I understand that false or misleading statements may result in enforcement action, citations, penalties, or revocation of inspection approval. 

    
    

32. California Perjury Declaration

    I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. 

34. Sign and Submit

    Please fill in the fields below to complete your self-certification form. A printable copy will be provided after successfully submitting the form.  

36. Printed Name*
38. Title/Relationship to Property*
40. Disclosure

    By typing my name above, I understand and agree that this constitutes my legal signature, executed electronically, with the same force and effect as a handwritten signature, pursuant to California Civil Code § 1633.1 et seq. (Uniform Electronic Transaction Act). 

Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit Submit and Print

* indicates a required field