Pg: _____________________

Rubrica(s):
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ANEXO J

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Ao Sr. Comandante do Corpo de Bombeiros Militar

Encaminho a V.S., formulrio para

Requerimento

Consulta Tcnica

PSPCI N_____________

FORMULRIO DE ATENDIMENTO E CONSULTA TCNICA FACT

1. IDENTIFICAO DA EDIFICAO OU REA DE RISCO DE INCNDIO
Razo Social:
Nome Fantasia:
CNPJ:
Logradouro:
N:

Complemento:

Municpio:

Bairro:
CEP:

2. IDENTIFICAO DO PROPRIETRIO OU RESPONSVEL PELO USO DA EDIFICAO (mediante procurao)

Nome do Proprietrio:
CPF:

Telefone:

E-mail:

Telefone:

E-mail:

Nome do responsvel pelo uso:

CPF:

3. IDENTIFICAO DO RESPONSVEL TCNICO PELO PPCI (Obrigatrio somente para PSPCI de risco mdio)
Nome:
CPF:

Telefone:

Formao profissional:

E-mail:
N CREA/CAU:

4. DOCUMENTOS JUNTADOS O FACT

Comprovante de pagamento de taxa de servio no emergencial

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Pg: _____________________
Rubrica(s):
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ANEXO J

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5. OBJETO DO REQUERIMENTO OU CONSULTA TCNICA E FUNDAMENTAO LEGAL

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______________, RS, ____ de ______________ de ________

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____________________________

Propietrio e/ou
Proprietrio
e/ou responsvel
responsvel pelo
pelo uso
uso da
da edificao
edificao

ResponsvelTcnico
tcnico pelo PPCI
Responsvel
PSPCI

Pg: _____________________

ANEXO J

Rubrica(s):
__________________________
__________________________

6. DESPACHO (para preenchimento do CBMRS)

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______________, RS, ____ de ______________ de ________
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NOME
POSTO
NOME DO
DO OFICIAL
OFICIAL ENCARREGADO
ENCARREGADO Posto
FUNO
Funo