Home safety inspections

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Home safety inspection

Please provide the following details

I am requesting an inspection for an owner-occupied, single-family home.

Yes

No

What type of vent is installed above your stove?

Vent hood

Microwave oven

Other

Contact information

First

Last

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email address

Phone

Fire prevention topics

Do you have any safety questions or topics you"d like our staff to cover?

Acceptance of waiver

Liability waiver (Home Safety Survey Program)

I understand that the Home Safety Survey Program (Program) is a voluntary, prevention-oriented home fire safety inspection program and that I have voluntarily invited the Bloomington Fire Department (BFD) into my home in order to perform a fire safety inspection. I understand this is an optional, courtesy outreach program by the BFD and it is not a replacement for a certificate of occupancy or other regulatory or compliance requirements.

In recognition of these facts and in consideration of the voluntary performance of a fire safety inspection of my home located at the address provided in this form (Home), I, on behalf of myself, and all members of family, as well as my heirs, executors, administrators or successors, hereby waive any and all claims or causes of action of any nature that I have, or may have, against any and all individuals or organizations participating in the Program, including but not limited to the BFD, the City of Bloomington, Minnesota and their officers, agents employees, and volunteers. I further hereby agree to release and hold harmless any and all individuals and organizations participating in the Program from and against all damages of any kind, to persons or property, arising or resulting from a fire or other damages in my Home. This includes but is not limited to providing or installing the safety equipment listed below or any safety education advice offered. I understand that the City of Bloomington and the BFD does not make any warranties as to the effectiveness of the safety equipment provided or installed. The only warranties applicable are those of the manufacturer of the safety equipment. I further agree that it is my responsibility to properly maintain or replace any safety equipment provided or installed by BFD.

By clicking the 'agree' option and entering my name in the electronic signature field below, I acknowledge having read, understood, and agreed to the above waiver, release, and hold harmless agreement.

Agree

Disagree

Signature

Please take notice that any data received by the City as the result of submitting this form will be classified as government data pursuant to the Minnesota Government Data Practices Act, Minnesota Statutes Chapter 13. Under the Data Practices Act, some or all of this data is classified as public data, including your name, address, email address, phone number, and other personal information provided by you. Public data is available to anyone requesting it and consists of all data furnished via this Web form. Please be advised that the correspondence will be added to the public record. The purpose and intended use of the information collected through this form is to obtain public input and data in support of City activities and services. You have the right to refuse to submit this form. If you choose not to submit this form, you will need to contact the City by another means if you wish to provide the information collected by the form.

The City of Bloomington does not discriminate against or deny the benefits of its services, programs, or activities to a qualified person because of a disability. To make a request for a reasonable accommodation, ask for more information, or to file a complaint, contact the Community Outreach and Engagement Division, City of Bloomington, 1800 West Old Shakopee Road, Bloomington, MN 55431- 3027; 952-563-8733, MN Relay 711.