Building Impairment Form.pdf

B. * TELEPHONE NUMBER:

FOB ANNEX NORTH & SOUTH

CIT

SPRINKLER / STAND PIPE VALVE

PUMP TELEPHONE

HALON SUPPLY

DETECTION MISC. (COMPLETE BOX 5)

FIRE COMMAND NOTIFIED O&M SERVICE PROVIDER NOTIFIED

IMPAIRED DEVICES DISABLE ON FIRE PANEL IMPAIRED DEVICE TAGGED

CENTRAL STATION MONITORING NOTIFIED HOT WORK PERMIT ISSUED - GSA FORM 1755, (COPY ATTACHED)

PM BUILDING INSPECTOR NOTIFIED FOR EXTRA PATROLS

EXTRA FIRE EXTINGUISHERS STAGGED IN IMPAIRMENT AREA

CONTRACTOR INFORMED CUTTING AND WELDING BANNED IN AFFECTED AREA

11. SYSTEM RESTORED: YES CHECKED

C. DATE: D. TIME:

8. EMERGENCY PRECAUTIONS COMPLETLED:

GSA FORM 1755S (REV. 7-15)

FROM:

C. * ROOM LOCATION(S):

TO:

B. * IMPAIRMENT STOP:A. * IMPAIRMENT START:

A. SIGNATURE:

A. SIGNATURE: C. DATE:

9. BMO REPRESENTATIVE AUTHORIZING IMPAIRMENT:

B. NAME AND TITTLE:

1. * COMPANY NAME:

TIME:

A. * NAME OF EMERGENCY CONTACT:

2. * LOCATION OF

IMPAIRMENT:

B. * FLOOR LOCATION(S):

FIRE PROTECTION SYSTEM

IMPAIRMENT NOTIFICATION

* SECTION TO BE COMPLETED BY CONTRACTOR/PROJECT MANAGER

A. * BUILDING LOCATION(S):

4. * IMPAIRED SYSTEM TYPE:3. * DATE OF IMPAIRMENT:

B. NAME AND TITTLE:

SECTION TO BE COMPLETED BY BMO/FIRE COMMAND REPRESENTATIVES

TIME:

C. DATE:

5. * EXPLANATION OF IMPAIRMENT TYPE AND AREA(S) AFFECTED:

6. * FIRE WATCH CERTIFICATE HOLDER(S)

7. * GSA PROJECT MANAGER REQUESTING IMPAIRMENT:

10. FIRE COMMAND REPRESENTATIVE ACKNOWLEDGING IMPAIRMENT:

GENERAL SERVICES ADMINISTRATION

A. SIGNATURE: B. NAME AND TITTLE:

^ SECTION TO BE COMPLETED BY O&M/FIRE COMMAND REPRESENTATIVE

A. SIGNATURE: B. NAME AND TITTLE: C. DATE:

203 CENTER ST. GARAGE

Sheet1

1:

Check Box6: Off