10. Exhibit H_Form12000 FLS PartA v-Dec2018_VA-GP.docx
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- Solicitation number
- 36C24W26R0012
- Issued by
-
Department of Veterans Affairs
About this file
This file is a GSA Form 12000, a Pre-Lease Fire Protection and Life Safety Evaluation template for office buildings designed to assess compliance with fire safety and life safety codes prior to lease execution.
The form is divided into two parts based on the location of the proposed space within the building: Part A applies to space below the 6th floor and must be completed by the offeror or their authorized representative; Part B applies to space on or above the 6th floor and must be completed by a professional engineer. All evaluations must verify compliance with the most recent edition of the building and fire code adopted by the jurisdiction, with egress requirements assessed against the National Fire Protection Association (NFPA) 101 Life Safety Code. The form requires building address and general building information, including identification of floors offered, total floor count, and floors permitting reentry from exit stairs. Part A consists of yes/no/not applicable questions addressing: automatic fire sprinkler system installation and maintenance; fire alarm system presence, emergency voice/alarm communication capabilities, and audible and strobe devices on the offered floor; exit signs and emergency lighting in egress paths; and elevator installations with two-way communication and smoke detector recall systems. The offeror must attest to the accuracy and completeness of all information provided by signing and dating the "Offeror's Statement." This evaluation is required as part of the Department of Veterans Affairs' Request for Lease Proposals for a 33,992 RSF Community Based Outreach Clinic in Olympia, Washington, with a 20-year lease term (15 firm, 5 soft years).
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Text version
EXHIBIT H
PRELEASE
FIRE PROTECTION AND LIFE SAFETY EVALUATION FOR AN OFFICE BUILDING
The prelease form contains two parts that must be completed depending on which floor the proposed offered space is located within a building. Part A must be completed when an offered space is located below the 6th floor of a building. Part A shall be completed by the Offeror or their authorized representatie. Part B must be completed when an offered space is located on or above the 6th floor of a building. Part B shall be completed by a professional engineer. The Fundamental Code Requirements apply to Part A and Part B.
Fundamental Code Requirements
| a. | The offered building shall be evaluated for compliance with the most recent edition of the building and fire code adopted by the jurisdiction in which the building is located; with the exception that the technical egress requirements of the building shall be evaluated based on the egress requirements of the most recent edition of the National Fire Protection Association (NFPA) 101, Life Safety Code. (Note: a building with a Certificate of Occupancy indicating that a building fully complies with the International Building Code shall be deemed to comply with this requirement.) All areas that do not meet the above stated criteria shall be identified as to the extent that they do comply. |
| b. | A fire escape located on the floor(s) where the offered space is located shall not be counted as an approved exit stair. |
| c. | An interlocking or scissor stair located on the floor(s) where the offered space is located shall only count as one exit stair. |
| d. | The number of floors used to determine when Part A or Part B is applicable is based on counting the number of floors starting from the street floor. |
PART A
The Offeror or their representative shall complete Part A. Part A consists of a series of short answer and yes/no/not applicable questions related to general building information and fire protection and life safety systems. Upon completion of Part A, the Offeror must sign and date the “Offeror’s Statement”. Part A is applicable to offered space located below the 6th floor of the building.
I. BUILDING ADDRESS
| Building Name: |
| Building Address: |
| City: |
| State: |
9-Digit Zip Code:
II. GENERAL BUILDING INFORMATION
| a. Identify each floor on which space is offered and the square footage of space on each floor offered to Government: |
| Floor |
| Sq. Ft. Per Floor |
| b. Identify the total number of floors in the building starting at the street floor: |
| c. Identify the total number of floors in the building below the street floor: |
| d. Identify which floor(s) in the building permit reentry from the exit stair enclosure to the interior of the building: |
III. OTHER USES IN BUILDING (Check All That Apply)
| |_| |
| Restaurants |
| |_| |
| Laboratories |
| |_| |
| Storage |
| |_| |
| Retail |
| |_| Parking Garage |
| |_| |
| Other (list) |
IV. AUTOMATIC FIRE SPRINKLER SYSTEM
| Please Check YES, NO, or N/A to the following questions: |
| YES |
| NO |
| N/A |
a. a. Is an automatic fire sprinkler system installed throughout the building?
b. b. If automatic fire sprinklers are installed within the building, is the automatic fire sprinkler system maintained in accordance with the applicable local codes or NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems?
V. FIRE ALARM SYSTEM
| Please Check YES, NO, N/A to the following questions: |
| YES |
| NO |
| N/A |
a. a. Is a fire alarm system installed in the building?
b. b. Is an emergency voice/alarm communication system installed in the building?
c. c. If a fire alarm system is installed in the building, are audible devices (e.g., horns, bells, speakers, etc.) installed on the floor in which the offered space is located in the building?
d. d. If a fire alarm system is installed in the building, are strobe devices installed on the floor in which the offered space is located in the building?
e. e. If a fire alarm system is installed in the building, is the fire alarm system over 25 years old?
f. f. If a fire alarm system is installed in the building, does the operation of the fire alarm system automatically notify the local fire department, remote station, or UL listed central station?
g. If a fire alarm system is installed in the building, is the fire alarm system maintained in accordance with the applicable local codes or NFPA 72, National Fire Alarm and Signaling Code?
VI. EXIT SIGNS & EMERGENCY LIGHTING
| Please Check YES, NO, or N/A to the following questions: |
| YES |
| NO |
| N/A |
a. a. Are exit signs installed in the paths of egress travel to the exit stairs or exits?
a. b. Is emergency lighting installed in the paths of egress travel to the exit stairs or exits?
b. c. If an emergency lighting system is installed in the building, is the emergency lighting system arranged to provide illumination automatically in the event of any interruption of the building’s normal lighting system?
VII. ELEVATORS
| Please Check YES, NO, or N/A to the following questions: |
| YES |
| NO |
| N/A |
Are elevators installed in the building?
If elevators are installed in the building, are the elevator cars equipped with a telephone or another two-way communication system?
If elevators are installed in the building, are the elevators recalled by smoke detectors located in the elevator lobbies and elevator machine rooms?
VIII. ADDITONAL INFORMATION
OFFEROR’S STATEMENT
I hereby attest that the above information is complete and accurate to the best of my knowledge.
Signature: Date:
Printed Name:
Title:
Name of Firm:
GENERAL SERVICES ADMINISTRATION PAGE 1 of 3 GSA FORM 12000 (April 2011)
File details come from the government source that posted it. Updated .