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Members
Department
Chiefs
Company 1
Company 2
Company 3
Benevolent
History
District
Recruitment
Vial of Life
Fire Safety/Prevention
About Us
Contact Us
Residential Questionnaire
* This information will remain confidential with the North Massapequa Fire Department and not disclosed with any other agency. The primary purpose of this information is to relay vital information to responding firefighter’s in the event of an emergency at your residence. The more accurate and descriptive you are with your responses, the quicker and safer our firefighters will be able to react, assist, and mitigate an emergency at your dwelling. We thank you in advance for your support and understanding with the value of this request and your cooperation with sending this information back. The Chiefs, Officers, and Members of the North Massapequa Fire Department
Name
First
Last
Address
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Phone
Emergency Contact Name
First
Last
Emergency Contact Phone
Construction
Type of House
Split
Colonial
Ranch
In-line Ranch
Hi-Ranch
Hi In-Line Ranch
Cape
Other - Specify Below
Other Type of House
Number of Floors (Exclude Basement and Attic)
1
1.5
2
2.5
3
3.5
4
Basement
Basement
Basement Outside Entrance
No Basement
Attic
Attic
No Attic
Apartment
Apartment (Specify Details Below)
No Apartment
Apartment Location Details
Describe any dormers or extensions made to home
Explain Layout of Home with as much description as known: (for instance, a split with 2 bedrooms on the second level, and one bedroom on the 3rd landing, unfinished basement)
Unconventional Rooms in Private Dwelling: such as a garage, basement, or other room converted to living quarters. Describe with as much detail as possible.
Other: Anything else that may aid our response efforts, Describe.
Garage
Detached
Attached
No Garage
Utilities
Electric: List all Main and Subpanels controlling the distribution of power within the home and the location of the exterior meter.
Generator
None
Side 1
Side 2
Side 3
Side 4
Manual Transfer Switch
Automatic Transfer Switch
Electric Vehicle Charging Station: If yes identify location
None
Garage (Interior)
Garage (Exterior)
Side 1
Side 2
Side 3
Side 4
Solar Panels (Describe location of exterior shutoff)
None
Side 1
Side 2
Side 3
Side 4
Gas (Describe location of main shutoff)
Interior
Exterior
Side 1
Side 2
Side 3
Side 4
Water (Describe location of main shutoff)
Side 1
Side 2
Side 3
Side 4
Fixed Propane Cylinders
Side 1
Side 2
Side 3
Side 4
Fireplace
Conventional Wood
Gas
Other, describe below
Fireplace Details - Other
Sprinklered Occupancy
Sprinklered Occupancy
No Sprinklers
Special Attention
Hazardous Materials: Please list (significant quantities only) hazardous materials. Write the amount of each product and the location of where it is stored.
Handicapped or Special Needs Occupant: Describe age, handicap, special needs and , location of occupant in house
Animals: Describe
Phone
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