12 GSA Form 12000 080626.pdf
GSA Form PDF 95 KB Posted
- Attached to
- U. S. Department of Agriculture Seeks to Lease Office and Related Space in Huntington, Indiana
- Solicitation number
- 57-18069-26-FA-RLP
About this file
GSA Form 12000 is a prelease fire protection and life safety evaluation template for office buildings submitted to the General Services Administration. The form requires evaluation of proposed space against the most recent building and fire codes adopted by the jurisdiction where the building is located, with the exception that egress requirements must be assessed against the National Fire Protection Association (NFPA) 101, Life Safety Code. The form is divided into two parts based on building floor location: Part A applies to space below the 6th floor and must be completed by the offeror or their authorized representative, while Part B applies to space on or above the 6th floor and must be completed by a professional engineer.
Part A consists of eight sections requiring documentation of building address, general building information (floor count and square footage), other uses in the building, and the presence and maintenance status of fire protection systems including automatic fire sprinklers, fire alarm systems with audible and strobe devices, emergency voice/alarm communication systems, exit signs, and emergency lighting. Additional requirements address elevator safety features such as two-way communication systems and smoke detector-activated recalls. The form specifies that fire escapes cannot be counted as approved exits, interlocking or scissor stairs count only as a single exit stair, and floor numbering begins from the street floor. The offeror must sign and date an attestation statement confirming the accuracy and completeness of the provided information.
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Text version
PRELEASE
FIRE PROTECTION AND LIFE SAFETY EVALUATION FOR AN OFFICE BUILDING
GENERAL SERVICES ADMINISTRATION PAGE 1 of 3 GSA FORM 12000 (May 2015)
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 representative. 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.
GENERAL SERVICES ADMINISTRATION PAGE 2 of 3 GSA FORM 12000 (May 2015)
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. Is an automatic fire sprinkler system installed throughout the building?
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. Is a fire alarm system installed in the building?
b. Is an emergency voice/alarm communication system installed in the building?
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. 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. If a fire alarm system is installed in the building, is the fire alarm system over 25 years old?
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 via any of the following means: directly to the local fire department, to the (911) public communications center, to a central station, to a remote supervising station, or to a proprietary supervising 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?
GENERAL SERVICES ADMINISTRATION PAGE 3 of 3 GSA FORM 12000 (May 2015)
VI. EXIT SIGNS & EMERGENCY LIGHTING
Please Check YES, NO, or N/A to the following questions: YES NO N/A
a. Are exit signs installed in the paths of egress travel to the exit stairs or exits?
b. Is emergency lighting installed in the paths of egress travel to the exit stairs or exits?
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:
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