PERMIT FOR PENETRATIONS AND MISCELLANEOUS OPENINGS IN FIRE AND SMOKE BARRIERS rv1.doc

PERMIT FOR ABOVE THE CEILING WORK AND PENETRATIONS IN FIRE AND SMOKE BARRIERS

VA Caribbean Health Care System

1. PURPOSE: Establish and maintain the integrity of Fire and Smoke barriers to limit the spread and restrict the movement of fire/smoke from one side of the barrier to the other.

2. POLICY: This policy applies to all vertical and horizontal penetrations in VA premises. The Facilities Management Service (FMS) establishes mechanisms to maintain the required fire rating of all floor-ceiling assemblies to comply with the standards established and accepted by NFPA 251.

3. DEFINITIONS:

(1) Breach or Penetration: Any hole, opening or fault created in a floor, ceiling assembly or wall that compromises the smoke tightness or fire rating of the penetrated barrier.

(2) Fire stop/smoke tight system: A system consisting of a specific process and material used to repair or seal any penetrations in fire and/or smoke wall barriers that meet specifications to ensure the original integrity and rating of the penetrated surface is restored.

(3) Fire barriers: Floors, ceiling assemblies, and walls, including supporting construction that meets the conditions of acceptance of NFPA 221, & NFPA 251. Fire barriers are designed and constructed with a specific fire resistance rating to not only limit the spread of fire but also restrict the movement of smoke. Compartments formed by fire barriers are constructed to be continuous from outside wall to outside wall, from one fire barrier to another or a combination thereof, including continuity through concealed spaces.

(4) Smoke barriers: Floors, ceiling assemblies, and walls that are designed and constructed to limit the movement of smoke from one area to another. Penetrations made through smoke barriers shall be protected by a system or material that can limit the transfer of smoke.

4. RESPONSIBILITY:

a. The Chief FMS is responsible for the implementation of this policy.

b. All Supervisors/Project Managers/Contracting Technical Representatives (COR) are responsible for ensuring compliance of this policy and complying with the reporting requirements delineated in Attachment 'A'.

c. The Safety Office is responsible for evaluating and issuing the work permit.

5. PROCEDURES:

a. Above the Ceiling Work

1) Prior to starting any work above the ceiling by any personnel, Attachment A must be completed and submitted to the Safety Office for approval. This excludes replacing damaged ceiling tiles, regular maintenance routine work above the ceiling, and emergency repair work such as water pipe leaks, etc. within four (4) hours in a 24-hour/day. Depending on the location or hazardous content of the area, permit required entry and/or Personal Protective Equipment and Control requirements to perform work or regular maintenance above the ceiling may be warranted. The service supervisor is responsible for providing this information to the employee and ensuring implementation of PPE and Control requirements.

2) Ceiling tiles will not be permitted to be out of place more than four (4) hours in a 24-hour/day in any VA Building. If ceiling tile replacement exceeds 4 hours, a permit will need to be completed by the responsible entity performing the work with an Interim Life Safety Measure with mitigating actions to compensate the Life Safety deficiency.

b. Penetrations in Fire/Smoke Barriers

1) Prior to making any breaches or penetrations in a fire/smoke barrier, Attachment 'A' must be completed and submitted to the Safety Office for approval.

2) A breach or penetration shall be filled with a material capable of maintaining the resistance of the barrier or protected by an approved device designed for this specific purpose.

3) Material to be used to fill the breach or penetration shall be UL approved intumescent fire stopping product with a minimum fire-resistant rating of the penetrated barrier.

4) A breach or penetration shall be filled and certified by an authorized firestop specialty contractor or factory-trained professional.

5) The areas to be filled may include, but is not limited to the following:

a) The space between the breach/penetration item and fire/smoke barrier

b) Around sleeves, where the breach/penetration item uses a sleeve to penetrate the fire/smoke barrier.

c) Around insulation and coverings for pipes and ducts

c. Additional Considerations

1) Where designs take transmission of vibration into consideration, any vibration isolation will be made on either side of the fire/smoke barrier or made by an approved device designed for the specific purpose.

2) Door or window assemblies in Fire Barriers will be of an approved type with appropriate rating for the location in which installed. Fire doors and windows will be installed in accordance with NFPA-80.

3) Doors in Smoke Barriers will close the opening a minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles. Where a fire resistance rating for smoke barriers is not specified elsewhere in the Code, the doors in smoke barriers will have a fire protection rating of at least 45 minutes. Vision panels in such doors will be approved transparent wired glass.

6. REFERENCES:

NFPA 101, Life Safety Code, Chapter 8, “Features of Fire Protection” & Chapter 9.2., “Heating Ventilation, and Air-Conditioning” (2018)

NFPA 221, Standard for High Challenge Fire Walls, Fire Walls, and Fire Barrier Walls (2015)

NFPA 251, Standard Methods of Tests of Fire Resistance of Building Construction and Materials (2006)

NFPA 80, Standard for Fire Doors and Other Opening Protectives (2019) Joint Commission EC and LS Requirements VHA CEOSH Fire Safety Guidebook

7. RESCISSION:

Facility Management Service: Maintenance and Repair Section Policy Memorandum No. 13-53, October 28th, 2013.

Wilfredo Quiñones

Chief FMS

ATTACHMENT “A”:

PERMIT FOR ABOVE THE CEILING WORK AND PENETRATIONS IN FIRE AND SMOKE BARRIERS

A. Rules and Regulations.

1. All Penetrations/breeches must be filled on the same day they are made.

2. U.L. approved fire stopping materials must be on site prior to making penetrations.

3. This permit is valid only for the period specified on the permit.

B. To be filled out by Project Manager/Supervisor/COR Date:___________ Company/Service:_____________________________ Person Requesting Permit (Please Print):______________________________ Project Name/Work Order Number:___________________________________ Location of Penetration/Breech Building #:___________ Frm Rm # _______To Rm # _______ Dia. of Breech:______Reason:___________ Frm Rm # _______To Rm # _______ Dia. of Breech:______Reason:___________ Frm Rm # _______To Rm # _______ Dia. of Breech:______Reason:___________ Signature of Requestor:_________________________ For Safety Office Use Only C. Number of breeches made through Fire Partition(s)______ Smoke Partition(s)_____ Fire/Smoke Stopping Materials on site: Yes_____ No_____

Type of Fire/Smoke Material to be used: ______________________________

Permit Approved By: _____________________ Title: ____________________

Permit Expiration Date: ___________________ Project Manager/Supervisor/COR Certification

D. Upon completion of work, area has been inspected and all penetrations/breeches have been filled with U.L. approved fire stopping (submit pictures of completed work):

Yes _____ No_____ Explain if not: __________________________________________________________________________________________________________________________________________________________________________________________________ Inspected By:__________________ Signature:____________________ Date:______