Smoke and Carbon Monoxide Alarm Declaration Form

Required fields are marked with asterisks (*)

Declaration of the installation of smoke and/or carbon monoxide alarms, batteries and the return to required standards

While attending your residence, Scugog Fire and Emergency Services observed contravention(s) of the Ontario Fire Code and provided you with an Assessment form. You are required by law to correct the noted deficiencies and ensure continued compliance with the Ontario Fire Code. Should you require further information or would like to schedule a re-inspection, please contact the Fire Prevention Division at 905-985-2384. By completing this Declaration Form, you are acknowledging that the remedial work noted on the Assessment Form has been completed.

Scugog Fire will accept this completed form as verification of compliance in lieu of a re-inspection if received within seven (7) days from the date of the Assessment form.

Please provide proof of purchase of any new smoke alarm or carbon monoxide alarm that was required to be installed by uploading a scan/photo of the receipt below.

Name:

Do you own or rent the property?

Owner

Tenant

Street Address:

Phone Number:

Email Address:

On this date, I corrected the deficiencies detailed below:

I was required to repair or replace the following (check all that apply):

Battery Operated Smoke Alarms

Batteries

Hard-Wired Smoke Alarm(s)

Carbon Monoxide Alarm(s)

Interconnection Functionality

Please provide brief details of the work completed (i.e. hard-wired smoke alarms were installed by an electrician on all 3 levels of my home):

Attach proof of purchase of new alarm(s):

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I hereby declare that as of this date, I have updated and will continue to maintain the level of smoke and carbon monoxide protection that was required in my residence at the time of construction.

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