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* 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
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Emergency Contact Name
Emergency Contact Phone
Type of House
Hi In-Line Ranch
Other - Specify Below
Other Type of House
Number of Floors (Exclude Basement and Attic)
Basement Outside Entrance
Apartment (Specify Details Below)
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.
Electric: List all Main and Subpanels controlling the distribution of power within the home and the location of the exterior meter.
Manual Transfer Switch
Automatic Transfer Switch
Electric Vehicle Charging Station: If yes identify location
Solar Panels (Describe location of exterior shutoff)
Gas (Describe location of main shutoff)
Water (Describe location of main shutoff)
Fixed Propane Cylinders
Other, describe below
Fireplace Details - Other
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
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