School Building I.D. # | _____________ | Inspection Completion Date | ________ | |||||||||||||||||||||
School District Name | ________________________________________________________ | |||||||||||||||||||||||
School Official Name | ________________________________________________________ | |||||||||||||||||||||||
School Building Name | ___________________________________________________ | |||||||||||||||||||||||
School Building Address | _________________________________________________ | |||||||||||||||||||||||
City | ________ | State | _________ | Zip | _________ | Phone | _________ | |||||||||||||||||
Total Square Footage | ___________ | Total School Occupancy | _______________ | |||||||||||||||||||||
Total Past Occupancy | ___________ | |||||||||||||||||||||||
Total Man Hours for Inspection | ___________ | |||||||||||||||||||||||
Total Man Hours for the Report Preparation | ___________ | |||||||||||||||||||||||
Inspection Company | _________________________________ | Phone | _______________ | |||||||||||||||||||||
Company Address | _________________________________________________________ | |||||||||||||||||||||||
City | _________ | State | ___________ | Zip | ____________________ | |||||||||||||||||||
________________________________ | ______________ | ______________ | ||||||||||||||||||||||
School Inspector's Signature | I.D. # | Date |
Ill. Admin. Code tit. 77, pt. 855, subpt. F, app B, ILLUSTRATION A