36E77618B0083-0001004.pdf

DEPARTMENT OF VETERANS AFFAIRS MEMORANDUM NO. 138-021

Central Arkansas Veterans Healthcare System April 25, 2018 Little Rock/North Little Rock

PENETRATION PERMIT POLICY

1. PURPOSE: To establish procedures regarding penetrations in floors, ceiling assemblies, or walls for the purpose of maintaining the integrity of the construction as required by NFPA 101, and The Joint Commission (TJC) to provide for the safety of occupants during fire incidents.

2. POLICY:

a. All penetrations made in floors, ceiling assemblies, or walls that would reduce the protection provided by fire barriers and smoke barriers, for the purpose of installing/removing pipe, conduit, cable, ductwork, other modifications including incidental damage, or the removal of such items, will be repaired/sealed upon completion of the work and documented as repaired. Temporary methods of sealing shall be used if work cannot be completed within 24 hours. This policy applies to all vertical and horizontal penetrations and to all VA staff and contractors.

b. Definitions:

(1) 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.

(c) 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.

(d) 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 is capable of limiting the transfer of smoke.

3. RESPONSIBILITY:

a. All Services that are involved with making penetrations through floors, ceiling assemblies, or walls, must be knowledgeable of the requirements of this policy with respect to equipment installations or penetrations that are coordinated within their assigned building spaces.

VHALITRISNEM

Text Box

APPENDIX E

2.

MEMORANDUM NO. 138-021

b. Safety Office staff will:

(1) Issue “Fire/Smoke Barrier Penetration Permits” (Attachment A) to staff and Contractors.

(2) Completed work approval be done by the Contract Officer Representative (COR) for the project or in-house Engineering Supervisor. In addition, Safety staff will periodically inspect and approve completed work.

c. Project Engineers, COR’s, OI&T/Information Management Service, and other staff coordinating or performing such work are responsible for compliance with this policy and ensuring that reference for compliance with this policy is included in all construction/installation contracts.

4. PROCEDURE:

a. A Fire/Smoke Barrier Penetration Permit must be obtained from the Safety Office prior to installation of cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communication systems that pass-through fire/smoke barriers. The permit shall be kept available for inspection at the designated site(s) until the work is completed.

b. During the permit approval process, the “Fire and Smoke Wall Drawings” will be reviewed to ensure that all fire/smoke barriers affected by the work are identified prior to permit approval and start of work.

c. Permits will be approved by the COR, in-house Engineering Supervisor or the Safety Office staff and will include a review of the location and scope of work with the individual(s) performing the work.

d. After the work is completed, the penetration must be repaired (sealed) according to accepted practice and utilizing approved fire stopping systems for penetrations of fire barriers and smoke tight systems for penetrations of smoke barriers.

e. Upon completion of any penetration repair, a visual inspection for approval must be requested by the permit holder to the COR, in-house Engineering supervisor or the Safety Office staff.

f. The completed “Fire/Smoke Barrier Penetration Permit” will be signed by the user/responsible person(s) and the COR, in-house Engineering Supervisor or Safety Office staff. Records shall be forwarded to, and maintained by the Safety Office.

5. REFERENCES:

a. NFPA 101, Life Safety Code, Chapter 8, “Features of Fire Protection” & Chapter 9.2., “Heating Ventilation, and Air-Conditioning” (2015)

3.

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

6. RESCISSION: NA

7. REVIEW: Engineering (138)

/s/

MARGIE A. SCOTT, M.D.

Medical Center Director

Attachments (1)

4.

Attachment A

FIRE/SMOKE BARRIER PENETRATION PERMIT

Contractor or VA Service/Section __________________________________________

Responsible Person ____________________________________________________

Telephone number/Email ______________________________________________

Location of work (building(s), floor(s), room number(s)) ___________________________

Scope of work _________________________________________________________

Drawings Reviewed? Yes No (circle one)

Type of Repair Materials used:

Firestopping ___________________________________________________________

Wall board ____________________________________________________________

Other _________________________________________________________________

Reviewed by ____________________________________

Approving Official and Title Date

Upon completion of work, the COR, in-house Engineering Supervisor or Safety Office staff will visually inspect the area to ensure compliance with requirements.

Inspected by _____________________________ Date ______________________

Approving Official and Title ____________________________________________

Comments ___________________________________________________________