9UT2187_RLP (Combined).pdf

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LESSOR'S ANNUAL COST STATEMENT

Important - Read attached "Instructions"

OMB Control Number: 3090-0086 Expiration Date: 1/31/2026

4. Building Name and Address (Number, Street, City, State, and Zip Code)

SECTION I - ESTIMATED ANNUAL COST OF SERVICES AND UTILITIES

FURNISHED BY LESSOR AS PART OF RENTAL CONSIDERATION

3. Rental Area (Square Feet)

SERVICES AND UTILITIES

A. CLEANING, JANITOR AND/OR CHAR SERVICE

B. HEATING

C. ELECTRICAL

D. PLUMBING

5. Salaries

FOR GOVERNMENT

USE ONLY

LESSOR'S ANNUAL COST FOR

(a) Entire Building

8. Salaries

10. System Maintenance and Repair

11. Current for Light and Power

12. Replacement of Bulbs, Tires, Starters

13. Power for Special Equipment

9. Fuel ("X" one)

E. AIR CONDITIONING

F. ELEVATORS

GSA 1217 (REV. 11/2016)

6. Supplies (Wax, cleaners, cloths, etc.)

7. Contract Services (Window washing, waste and snow removal)

14. System Maintenance and Repair (Ballasts, Fixtures, etc.)

15. Water (For all purposes) (Include Sewage Charges)

16. Supplies (Soap, towels, tissues not in 6 above)

(b) Government-Leased Area

3A. Entire Building

2. Statement Date

3B. Leased by Government

1. Request for Lease Proposals (RLP)

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 3090-0086. We estimate that it will take 2 hours to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.

17. System Maintenance and Repair

18. Utilities (Include electricity, if not in C11)

19. System Maintenance and Repair

21. System Maintenance and Repair

GENERAL SERVICES ADMINISTRATION

20. Salaries (Operators, starters, etc.)

Oil Gas Coal Electric

G. MISCELLANEOUS (To the extent not included on Page 1)

22. Building Engineer and/or Manager

23. Security (Watchperson, guards, not janitors)

25. Lawn and Landscaping Maintenance

26. Other (Explain on separate sheet)

27. TOTAL

34. Signature of:

28. Real Estate Taxes

29. Insurance (Hazard, Liability, etc.)

30. Building Maintenance and Reserves for Replacement

31. Lease Commission

32. Management

TYPED NAME AND TITLE SIGNATURE DATE

34C.

35A. 35B. 35C.

LESSOR'S CERTIFICATION - The amounts entered in Columns (a) and (b) represent my best estimate as to the annual costs of services, utilities, and ownership.

33. TOTAL

34A.

24. Social Security Tax and Workperson's Compensation Insurance

SECTION II - ESTIMATED ANNUAL COST OF OWNERSHIP EXCLUSIVE OF CAPITAL CHARGES

34B.

GSA 1217 (REV. 11/2016) PAGE 2

Owner Legal Agent

INSTRUCTIONS

In acquiring space by lease, it is the established policy of GSA to enter into leases only at rental charges which are consistent with prevailing scales in the community for facilities.

ITEM NUMBER

SECTION I

ESTIMATED ANNUAL COST OF SERVICES AND UTILITIES

SECTION II

ESTIMATED ANNUAL COST OF OWNERSHIP EXCLUSIVE OF CAPITAL CHARGES

1. Enter the Government lease or Request for Lease Proposals (RLP) number, if available.

2. Enter the date that your statement was prepared and signed.

3. A. Enter in this block a computation of the rentable area (multiple tenancy basis) for the entire building. The rentable area shall be computed by measurement to the inside finish of permanent outer building walls to the inside finish of corridor walls (actual or proposed) or to other permanent partitions, or both. Rentable space is the area for which a tenant is charged rent. It is determined by the building owner and may vary by city or by building within the same city. The rentable space may include a share of building support/common areas such as elevator lobbies, building corridors, and floor service areas. Floor services areas typically include restrooms, janitor rooms, telephone closets, electrical closets, and mechanical rooms.

The rentable space generally does not include the vertical building penetrations and their enclosing walls, such as stairs, elevator shafts, and vertical ducts.

3. B. Enter in this block a computation of the rentable area to be rented to the Government. For this area, follow the procedure as outlined above, except that measurements are to be made only to the center of the partitions which separate the area to be rented by the Government from adjoining rented or rentable areas.

4. Identify the property by name and address.

5. - 26. The services and utilities listed in this section are required in most of our rented space whether furnished by the Government or the Lessor.

Carefully review the Request for Lease Proposals (RLP) and/or the proposed lease to identify those services and utilities to be furnished by you as part of the rental consideration. Then enter your best cost estimate, or the actual cost from the previous year, for each of these services and utilities in column (a) for the entire building and in column (b) for the area to be rented to the Government. If any service or utility furnished for the space rented by the Government is not furnished throughout the building, or the cost of a service or utility furnished to the Government space exceeds the cost of the same service or utility furnished to other rented space, explain on a separate sheet. For convenience, each major category has been divided into separate items such as salaries and supplies so that they may be entered when applicable. However, in the event that your records are not maintained for each item contained in Section I, 5 through 26, the total for a major category (A through F) may be entered under the category heading in columns (a) and (b) in lieu of the specific items. System maintenance and repairs includes the annual cost of such items as oiling, inspecting, cleaning, regulating, and routine replacement costs.

Items 28 through 32 will be useful in the Government's determination of the fair market value of the space to be rented and shall be completed irrespective of whether Section I is applicable, as follows:

28. Include all applicable real estate taxes imposed upon the property.

29. Enter the annual cost of fire, liability, and other insurance carried on the real estate.

31. Enter any lease commission which you may be responsible for due to the Government leasing action.

32. Include administrative expenses such as agency fees, legal fees, auditing, and advertising. Do not include financial charges such as income or corporate taxes or organization expense.

34. - 35. Complete Lessor certification.

30. Enter the annual cost of wages, materials, and outside services used in repairs and maintenance of the building itself and all similar repairs and maintenance of the building itself and all similar repairs and maintenance costs not included in Section I above (Heating, Electrical, Plumbing, Air Conditioning, and Elevators). This includes major repairs and changes in the nature of a permanent improvement such as annual cost to replace relatively short-lived items such as boiler, compressors, elevators, and roof coverings.

GSA 1217 (REV. 11/2016) PAGE 3

LESSOR'S ANNUAL COST STATEMENT

Important - Read attached "Instructions"

OMB Control Number: 3090-0086 Expiration Date: 1/31/2026

4. Building Name and Address (Number, Street, City, State, and Zip Code)

SECTION I - ESTIMATED ANNUAL COST OF SERVICES AND UTILITIES FURNISHED BY LESSOR AS PART OF RENTAL CONSIDERATION

3. Rental Area (Square Feet)

SERVICES AND UTILITIES

A. CLEANING, JANITOR AND/OR CHAR SERVICE

B. HEATING

C. ELECTRICAL

D. PLUMBING

5. Salaries

FOR GOVERNMENT USE ONLY

LESSOR'S ANNUAL COST FOR

(a) Entire Building

8. Salaries

10. System Maintenance and Repair

11. Current for Light and Power

12. Replacement of Bulbs, Tires, Starters

13. Power for Special Equipment

9. Fuel ("X" one)

E. AIR CONDITIONING

F. ELEVATORS

GSA 1217 (REV. 11/2016)

6. Supplies (Wax, cleaners, cloths, etc.)

7. Contract Services (Window washing, waste and snow removal)

14. System Maintenance and Repair (Ballasts, Fixtures, etc.)

15. Water (For all purposes) (Include Sewage Charges)

16. Supplies (Soap, towels, tissues not in 6 above)

(b) Government-Leased Area

3A. Entire Building

2. Statement Date

3B. Leased by Government

1. Request for Lease Proposals (RLP)

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 3090-0086. We estimate that it will take 2 hours to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.

17. System Maintenance and Repair

18. Utilities (Include electricity, if not in C11)

19. System Maintenance and Repair

21. System Maintenance and Repair

GENERAL SERVICES ADMINISTRATION

20. Salaries (Operators, starters, etc.)

G. MISCELLANEOUS (To the extent not included on Page 1)

22. Building Engineer and/or Manager

23. Security (Watchperson, guards, not janitors)

25. Lawn and Landscaping Maintenance

26. Other (Explain on separate sheet)

27. TOTAL

34. Signature of:

28. Real Estate Taxes

29. Insurance (Hazard, Liability, etc.)

30. Building Maintenance and Reserves for Replacement

31. Lease Commission

32. Management

TYPED NAME AND TITLE

SIGNATURE

DATE

LESSOR'S CERTIFICATION - The amounts entered in Columns (a) and (b) represent my best estimate as to the annual costs of services, utilities, and ownership.

33. TOTAL

24. Social Security Tax and Workperson's Compensation Insurance

SECTION II - ESTIMATED ANNUAL COST OF OWNERSHIP EXCLUSIVE OF CAPITAL CHARGES

GSA 1217 (REV. 11/2016) PAGE 2

INSTRUCTIONS

In acquiring space by lease, it is the established policy of GSA to enter into leases only at rental charges which are consistent with prevailing scales in the community for facilities.

ITEM NUMBER

SECTION I

ESTIMATED ANNUAL COST OF SERVICES AND UTILITIES

SECTION II

ESTIMATED ANNUAL COST OF OWNERSHIP EXCLUSIVE OF CAPITAL CHARGES

1. Enter the Government lease or Request for Lease Proposals (RLP) number, if available.

2. Enter the date that your statement was prepared and signed.

3. A. Enter in this block a computation of the rentable area (multiple tenancy basis) for the entire building. The rentable area shall be computed by measurement to the inside finish of permanent outer building walls to the inside finish of corridor walls (actual or proposed) or to other permanent partitions, or both. Rentable space is the area for which a tenant is charged rent. It is determined by the building owner and may vary by city or by building within the same city. The rentable space may include a share of building support/common areas such as elevator lobbies, building corridors, and floor service areas. Floor services areas typically include restrooms, janitor rooms, telephone closets, electrical closets, and mechanical rooms.

The rentable space generally does not include the vertical building penetrations and their enclosing walls, such as stairs, elevator shafts, and vertical ducts.

3. B. Enter in this block a computation of the rentable area to be rented to the Government. For this area, follow the procedure as outlined above, except that measurements are to be made only to the center of the partitions which separate the area to be rented by the Government from adjoining rented or rentable areas.

4. Identify the property by name and address.

5. - 26. The services and utilities listed in this section are required in most of our rented space whether furnished by the Government or the Lessor. Carefully review the Request for Lease Proposals (RLP) and/or the proposed lease to identify those services and utilities to be furnished by you as part of the rental consideration. Then enter your best cost estimate, or the actual cost from the previous year, for each of these services and utilities in column (a) for the entire building and in column (b) for the area to be rented to the Government. If any service or utility furnished for the space rented by the Government is not furnished throughout the building, or the cost of a service or utility furnished to the Government space exceeds the cost of the same service or utility furnished to other rented space, explain on a separate sheet. For convenience, each major category has been divided into separate items such as salaries and supplies so that they may be entered when applicable. However, in the event that your records are not maintained for each item contained in Section I, 5 through 26, the total for a major category (A through F) may be entered under the category heading in columns (a) and (b) in lieu of the specific items. System maintenance and repairs includes the annual cost of such items as oiling, inspecting, cleaning, regulating, and routine replacement costs.

Items 28 through 32 will be useful in the Government's determination of the fair market value of the space to be rented and shall be completed irrespective of whether Section I is applicable, as follows:

28. Include all applicable real estate taxes imposed upon the property.

29. Enter the annual cost of fire, liability, and other insurance carried on the real estate.

31. Enter any lease commission which you may be responsible for due to the Government leasing action.

32. Include administrative expenses such as agency fees, legal fees, auditing, and advertising. Do not include financial charges such as income or corporate taxes or organization expense.

34. - 35. Complete Lessor certification.

30. Enter the annual cost of wages, materials, and outside services used in repairs and maintenance of the building itself and all similar repairs and maintenance of the building itself and all similar repairs and maintenance costs not included in Section I above (Heating, Electrical, Plumbing, Air Conditioning, and Elevators). This includes major repairs and changes in the nature of a permanent improvement such as annual cost to replace relatively short-lived items such as boiler, compressors, elevators, and roof coverings.

GSA 1217 (REV. 11/2016) PAGE 3

11.0.0.20130303.1.892433.887364

GSA 1217 - Lessor's Annual Cost Statement

4. Enter the Building Name and Address (Number, Street, City, State, and Zone Improvement Plan (ZIP) Code):

5a. Cleaning, Janitor and/or Char Service. Enter the Lessor's Annual Cost for Salaries for the Entire Building. :

5b. Cleaning, Janitor and/or Char Service. Enter the Lessor's Annual Cost for Salaries for the Government-Leased Area. :

5. Cleaning, Janitor and/or Char Service. Salaries: For Government Use Only.:

11a. Electrical. Enter the Lessor's Annual Cost for Current for Light and Power for the Entire Building.:

11b. Electrical. Enter the Lessor's Annual Cost for Current for Light and Power for the Government-Leased Area.:

11. Electrical. Enter the Lessor's Annual Cost for Current for Light and Power For Government Use Only.:

8a. Heating. Enter the Lessor's Annual Cost for Salaries for the Entire Building. :

8b. Heating. Enter the Lessor's Annual Cost for Salaries for the Government-Leased Area.:

8. Heating. Salaries: For Government Use Only.:

15a. Plumbing. Enter the Lessor's Annual Cost for Water (for all purposes) (include Sewage Charges) for the Entire Building. :

15b. Plumbing. Enter the Lessor's Annual Cost for Water (For all purposes) (Include Sewage Charges) for the Government-Leased Area.:

15. Plumbing. Water (For All Purposes) (Include Sewage Charges) For Government Use Only.:

18a. Air Conditioning. Enter the Lessor's Annual Cost for Utilities (Include Electricity, if not in C11) for the Entire Building.:

20b. Elevators. Enter the Lessor's Annual Cost for Salaries (Operators, starters, etc.) for the Government-Leased Area.:

20. Elevators. Salaries (Operators, starters, etc.) For Government Use Only.:

20a. Elevators. Enter the Lessor's Annual Cost for Salaries (Operators, starters, etc.) for the Entire Building. :

18b. Air Conditioning. Enter the Lessor's Annual Cost for Utilities (Include electricity, if not in C11) for the Government-Leased Area.:

18. Air Conditioning. Utilities (include electricity if not in C11) For Government Use only.:

6a. Cleaning, Janitor and/or Char Service. Enter the Lessor's Annual Cost for Supplies (Wax, cleaners, cloths, etc.) for the Entire Building. :

6b. Cleaning, Janitor and/or Char Service. Enter the Lessor's Annual Cost for Supplies (Wax, cleaners, cloths, etc.) for the Government-Leased Area.:

6. Supplies (Wax, cleaners, cloths, etc.) For Government Use Only.:

7a. Cleaning, Janitor and/or Char Service. Enter the Lessor's Annual Cost for Contract Services (Window washing, waste and snow removal) for the Entire Building. :

7b. Cleaning, Janitor and/or Char Service. Enter the Lessor's Annual Cost for Contract Services (Window washing, waste and snow removal) for the Government-Leased Area.:

7. Contract Services (Window washing, waste, and snow removal) For Government Use Only.:

9a. Heating. Enter the Lessor's Annual Cost for Fuel for the Entire Building. :

9b. Heating. Enter the Lessor's Annual Cost for Fuel for the Government-Leased Area.:

9. Heating. Fuel: For Government Use Only.:

10a. Heating. Enter the Lessor's Annual Cost for System Maintenance and Repair for the Entire Building. :

10b. Heating. Enter the Lessor's Annual Cost for System Maintenance and Repair for the Government-Leased Area.:

10. Heating. System Maintenance and Repair For Government Use Only.:

12a. Electrical. Enter the Lessor's Annual Cost for Replacement of Bulbs, Tires, and Starters for the Entire Building. :

12b. Electrical. Enter the Lessor's Annual Cost for Replacement of Bulbs, Tires, and Starters for the Government-Leased Area.:

12. Electrical. Replacement of Bulbs, Tires and Starters For Government Use Only.:

13a. Electrical. Enter the Lessor's Annual Cost for Power for Special Equipment for the Entire Building.:

13b. Electrical. Enter the Lessor's Annual Cost for Power for Special Equipment for the Government-Leased Area.:

13. Electrical. Enter the Lessor's Annual Cost for Power for Special Equipment For Government Use Only. :

14a. Electrical. Enter the Lessor's Annual Cost for System Maintenance and Repair (Ballasts, Fixtures, etc.) for the Entire Building. :

14b. Electrical. Enter the Lessor's Annual Cost for System Maintenance and Repair (Ballasts, Fixtures, etc.) for the Government-Leased Area. :

14. Electrical. Enter the Lessor's Annual Cost for System Maintenance and Repair (Ballasts, Fixtures, etc.) For Government Use Only. :

16a. Plumbing. Enter the Lessor's Annual Cost for Supplies (Soap, towels, tissues not in 6 above) for the Entire Building.:

16b. Plumbing. Enter the Lessor's Annual Cost for Supplies (Soap, towels, tissues not in 6 above) for the Government-Leased Area.:

16. Plumbing. Enter the Lessor's Annual Cost for Supplies (Soap, towels, tissues not in 6 above) For Government Use Only.:

3. Enter the Rental Area in Square Feet.:

3A. Enter the Entire Building info.:

2. Enter the Statement Date (enter 2 digit month, 2 digit day, and 4 digit year).:

3B. Enter the Leased by Government info.:

17. Plumbing. System Maintenance and Repair For Government Use Only.:

19a. Air Conditioning. Enter the Lessor's Annual Cost for System Maintenance and Repair for the Entire Building.:

19b. Air Conditioning. Enter the Lessor's Annual Cost for System Maintenance and Repair for Government-Leased Area.:

19. Air Conditioning. System Maintenance and Repair for Government Use Only. :

21a. Elevators. Enter the Lessor's Annual Cost for System Maintenance and Repair for the Entire Building.:

21b. Elevators. Enter the Lessor's Annual Cost for System Maintenance and Repair for the Government-Leased Area. :

21. Elevators. Enter the Lessor's Annual Cost for System Maintenance and Repair For Government Use Only. :

17b. Plumbing. Enter the Lessor's Annual Cost for System Maintenance and Repair for the Government-Leased Area.:

17a. Plumbing. Enter the Lessor's Annual Cost for System Maintenance and Repair for the Entire Building. :

Heating. Click here to choose Oil as the fuel type.: 0

Heating. Click here to choose Gas as the fuel type. : 0

Heating. Click here to choose Coal as the fuel type.: 0

Heating. Click here to choose Electric as the fuel type. : 0

22. Miscellaneous. Building Engineer and/or Manager For Government Use Only:

22b. Miscellaneous (to the extent not included on Page 1). Enter the Lessor's Annual Cost for Building Engineer and/or Manager for the Government-Leased Area.:

22a. Miscellaneous (to the extent not included on Page 1). Enter the Lessor's Annual Cost for Building Engineer and/or Manager for the Entire Building. :

23. Security (Watchperson, guards, not janitors) For Government Use Only.:

25a. Miscellaneous (to the extent not included on Page 1). Enter the Lessor's Annual Cost for Lawn and Landscaping Maintenance for the Entire Building. :

25b. Miscellaneous (to the extent not included on Page 1). Enter the Lessor's Annual Cost for Lawn and Landscaping Maintenance for the Government-Leased Area. :

25. Miscellaneous. Lawn and Landscaping Maintenance for Government Use Only.:

26a. Miscellaneous (to the extent not included on Page 1). Enter the Lessor's Annual Cost for Other (Explain on separate sheet) for the Entire Building.:

26b. Miscellaneous (to the extent not included on Page 1). Enter the Lessor's Annual Cost for Other (Explain on separate sheet) for the Government-Leased Area. :

26. Miscellaneous. Other (Explain on separate sheet) for Government Use Only.:

27a. Total for the Entire Building, Section I (this field is auto-calculated).:

27b. Total for the Government-Leased Area, Section I (this field is auto-calculated).:

27. Total, Section I, for Government Use Only.:

28a. Enter the Lessor's Annual Cost for Real Estate Taxes for the Entire Building.:

28b. Enter the Lessor's Annual Cost for Real Estate Taxes for the Government-Leased Area.:

28. Real Estate Taxes for Government Use Only.:

29a. Enter the Lessor's Annual Cost for Insurance (Hazard, Liability, etc.) for the Entire Building.:

29b. Enter the Lessor's Annual Cost for Insurance (Hazard, Liability, etc.) for the Government-Leased Area.:

29. Insurance (Hazard, Liability, etc.) for Government Use Only.:

30a. Enter the Lessor's Annual Cost for Building Maintenance and Reserves for Replacement for the Entire Building. :

30b. Enter the Lessor's Annual Cost for Building Maintenance and Reserves for Replacement for the Government-Leased Area.:

30. Building Maintenance and Reserves for Replacement for Government Use Only.:

31a. Enter the Lessor's Annual Cost for Lease Commission for the Entire Building. :

31b. Enter the Lessor's Annual Cost for Lease Commission for the Government-Leased Area.:

31. Lease Commission for Government Use Only.:

35c. If you are the person who entered their Name and Title in 35A, enter the date you signed this form (enter 2 digit month, 2 digit day, and 4 digit year).:

34a. Enter the First Typed Name and Title. :

34b. Sign here if you are the person who entered their Name and Title in 34A (First Signature).:

32a. Enter the Lessor's Annual Cost for Management for the Entire Building.:

32b. Enter the Lessor's Annual Cost for Management for the Government-Leased Area.:

32. Management for Government Use Only.:

33a. Total for the Entire Building, Section II (this field is auto-calculated).:

33b. Total for the Government-Leased Area, Section II (this field is auto-calculated).:

33. Total, Section II, for Government Use Only.:

24a. Miscellaneous (to the extent not included on Page 1). Enter the Lessor's Annual Cost for Social Security Tax and Workperson's Compensation Insurance for the Entire Building. :

24b. Miscellaneous (to the extent not included on Page 1). Enter the Lessor's Annual Cost for Social Security Tax and Workperson's Compensation Insurance for the Government-Leased Area. :

24. Miscellaneous. Social Security Tax and Workperson's Compensation Insurance For Government Use Only.:

23b. Miscellaneous (to the extent not included on Page 1). Enter the Lessor's Annual Cost for Security (Watchperson, guards, not janitors for the Government-Leased area.:

23a. Miscellaneous (to the extent not included on Page 1). Enter the Lessor's Annual Cost for Security (Watchperson, guards, not janitors) for the Entire Building.:

Click here to mark the signature of the Lessor's Certification as the Owner. : 0

Click here to mark the signature of the Lessor's Certification as the Legal Agent. : 0

PRELEASE

FIRE PROTECTION AND LIFE SAFETY EVALUATION FOR AN OFFICE BUILDING

GENERAL SERVICES ADMINISTRATION PAGE 1 of 6 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.

Exhibit H

GENERAL SERVICES ADMINISTRATION PAGE 2 of 6 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. 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 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 6 GSA FORM 12000 (May 2015)

VI. EXIT SIGNS & EMERGENCY LIGHTING

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

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 4 of 6 GSA FORM 12000 (May 2015)

PART B

The Offeror’s professional engineer shall complete Part B when an offered space is located on the 6th floor or higher of a building. Part B consists of a detailed narrative report based on an evaluation of the entire building that also includes a walk-through of the building and the review of the preventive maintenance records of the building’s fire alarm system and automatic fire sprinkler system. The fire protection engineer shall prepare a detailed narrative report. The detailed narrative report shall address at a minimum the items noted below as they apply to the offered space in the building, with specific attention to fire safety conditions that affect the floor(s) where the offered space to the Government is located, including those floors located below the offered space. In addition, the detailed narrative report shall include all deficiencies that do not meet the specified criteria (see Fundamental Code Requirements), the associated code reference(s), as well as any recommended corrective action(s).

NOTES:

a. The professional engineer must be licensed as a fire protection engineer in the same State in which the subject building is located unless the subject State does not formally recognize fire protection engineering. In such cases, GSA will accept the services of any professional engineer in the subject State provided the professional engineer is also recognized as a fire protection engineer in any other U.S. State or Territory.

b. Upon completion of Part B, the Offeror’s fire protection engineer must sign and date the “Fire Protection Engineer Statement.”

c. Upon completion of Part B, the Offeror must sign and date the “Offeror’s “Statement of Correction.”

d. The accepted GSA Form 12000, Part B is valid for a time period of 5 years from the noted date on the completed and accepted Part B.

This acceptance is conditional in that no major modifications or construction has occurred associated with the building.

The detailed narrative report shall address at a minimum the items noted below as they apply to the offered space in the building.

1. General Information.

a. Identify all current citations or violations noted by the local jurisdiction regarding the building.

b. Provide digital pictures of the building. Include exterior views showing the front of the building and all sides of the building.

c. Identify the number of floors in the building (above and below grade).

d. Identify the approximate gross square footage per floor in the building.

e. Identify the gross square footage and associated floor of offered space proposed to the Government to occupy.

f. Identify by location and describe hazardous/significant fuel load areas (greater than normal for the type of occupancy).

g. Identify and describe potential fire ignition sources in hazardous/significant fuel load areas in the building.

2. Occupancy Classifications.

a. Identify all the different types of occupancies and particular uses on each floor of the subject building. For example, include retail, restaurants, mechanical equipment areas, storage areas, inside parking areas, etc.

3. Building Construction.

a. Identify the building construction type.

4. Vertical Openings.

a. Identify by location and describe the enclosure of vertical openings through floors, such as stairways, atriums, hoistways for elevators, escalators, and shafts.

b. Identify any deficiencies in the rated vertical enclosures that affect the integrity of the enclosure.

5. Means of Egress.

a. Identify the number of enclosed exit stairs on each floor of the building.

b. For each exit stair, describe:

i. The clear width of each stair tread and location of measurement.

ii. The egress capacity of each exit stair.

iii. The location of where each exit stair discharges.

iv. Identify and describe the operation and application of the exit stair re-entry provisions to the interior of the building, if provided.

GENERAL SERVICES ADMINISTRATION PAGE 5 of 6 GSA FORM 12000 (May 2015)

v. Any penetrations into and openings through each exit stair enclosure assembly.

vi. Any headroom obstruction within each exit stair enclosure.

vii. If any exit stair has been compromised in such a way to have the potential to interfere with its use as an exit; and

viii. The exit stair remoteness arrangement.

ix. Identify and describe if all exit stair doors are self-closing and self-latching.

c. Identify and describe all exit doors that do not swing in the direction of exit travel.

d. Identify and describe if all fire doors are in proper working order. Provide location of noted fire door and purpose.

e. Identify by floor and describe any concerns regarding the exit access system (i.e., corridor or open plan office concept), as it applies to the proposed offered space.

f. Identify by location and describe any concern regarding the exit signage within the building.

g. Describe the building’s emergency lighting system.

h. Identify and describe if emergency power is provided within the building.

i. If emergency power for life safety systems is provided by generator(s) or UPS systems describe if they are tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems or NFPA 111, Standard on Stored Electrical Energy

Emergency and Standby Power Systems as applicable. If not complying with the applicable NFPA Standards; identify and evaluate the procedures being used.

6. Automatic Fire Suppression Systems.

a. Identify and describe if the building is protected or not protected throughout by an automatic fire sprinkler system. If the building is not protected throughout by an automatic fire sprinkler system, identify those areas of the building where partial fire sprinkler protection is provided.

b. Identify and describe the different types of automatic fire sprinkler systems (e.g., dry, wet, pre-action, etc.) that are installed within the building and their respective locations.

c. Identify and describe any other fire suppression systems installed within the building.

d. Identify and describe the types of standpipes installed in the building.

e. If automatic fire sprinkler systems are installed in the building, describe if they are tested and maintained in accordance with the applicable local codes or NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. If not complying with the applicable NFPA Standards; identify and evaluate the procedures being used. If not complying with the applicable NFPA

Standard; identify and evaluate the procedures being used.

7. Fire Alarm System.

a. Identify and describe the fire alarm system, as a minimum, the date of installation, type, manufacturer and model, and components such as manual pull stations, etc.

b. Describe if the fire alarm system automatically notifies 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.

c. Describe in detail the operation of the fire alarm system, including if it has emergency voice/alarm communication capabilities.

d. Describe if the fire alarm system is tested and maintained in accordance with NFPA 72, National Fire Alarm and Signaling Code. If not complying with the applicable NFPA Standard; identify and evaluate the procedures being used.

8. Elevators.

a. Verify the elevators have a current certificate (date of inspection) of elevator inspection from the local jurisdiction.

b. Identify and describe the emergency recall operation features of the elevators. Describe all differences with the requirements of

ASME/A17.1, Safety Code for Elevators and Escalators, Phase I Emergency Recall Operation requirements.

c. Identify and describe the emergency in car operation features of the elevators. Describe all differences with the requirements of

ASME/A17.1, Safety Code for Elevators and Escalators, Phase II Emergency In-Car Operation requirements.

d. Identify and describe if the elevators are equipped with telephones or other two-way emergency signaling systems connected to an emergency communication location staffed 24 hours per day, 7 days per week.

GENERAL SERVICES ADMINISTRATION PAGE 6 of 6 GSA FORM 12000 (May 2015)

STATEMENT OF FIRE PROTECTION ENGINEER

I hereby attest that I have performed a full assessment of the subject premises; and that the above information is complete and accurate to the best of my knowledge. I have initialed at the bottom of each page. My official seal, professional license information, and signature are affixed below.

I have included findings, recommended corrective action(s), and made specific references to the applicable code sections as an attachment to this report. Such findings specifically identify instances where the building does not comply with the specified criteria, and recommendations have been made in order to rectify the situation and assure substantial compliance of the building to all applicable criteria.

(If no deficiencies were identified, during the evaluation, please explicitly state so in the findings and recommendations portion of the report.)

Name of Firm: Phone #: ( ) -

License Number:

Stamp Here:

OFFEROR’S STATEMENT OF CORRECTION

In the event any of the offered space does not meet the above criteria, the Offeror shall attest below that all work required to bring the offered space into full compliance with all applicable criteria will be completed at the Offeror's sole cost and expense prior to the Government's acceptance of the offered space under the terms of any prospective lease agreement.

NOTE: REPORTS SUBMITTED WITHOUT THE FPE’S FINDINGS, RECOMMENDED CORRECTIVE ACTIONS

AND CODE REFERENCES WILL BE RETURNED WITHOUT REVIEW BY THE GSA REGIONAL FIRE

PROTECTION ENGINEERING OFFICE.

Title:

Name of Firm:

RLP OFFER ATTACHMENT - SEISMIC OFFER FORMS

Instructions for Offeror:

Forms A through D are pre-award submittals. Depending upon the form, either the Offeror or the Offeror’s engineer shall complete and sign the form to confirm seismic compliance with RP 8. When the engineer fills out a form, he or she is also required to stamp it. The Offeror’s engineer shall represent whether the Building meets RP 8 standards, using Form A for Benchmark Buildings or Form B for other existing buildings.

If the engineer’s certification indicates that the Building does not meet RP 8 standards, the Offeror shall agree to retrofit the building to meet the standards, using Form C, Part

1. Offerors providing new construction shall commit to a design code, using Form C, Part

2. Offerors may represent that their building meets an exemption criteria, using Form D.

Forms E and F are post-award submittals. They only apply when the Offeror has agreed to either retrofit an existing building (use Form E) or is constructing a new building (use Form F). Prior to the Government accepting leased space, the Lessor’s engineer shall complete, stamp, and sign the appropriate representation.

The forms must include the supporting documentation stated in the RLP and Lease.

Below is a detailed explanation of each of the forms.

SEISMIC FORM A - CERTIFICATE OF SEISMIC COMPLIANCE BENCHMARK BUILDING

A benchmark building is one that was designed and built or retrofitted in accordance with structural provisions that are considered to provide acceptable life-safety protection. RP 8, Section 1.3, Table 1-1 shows the construction codes that qualify a building as a Benchmark Building. If a building qualifies, no additional hazards need be considered. If the seismicity of a region has changed since the benchmark dates listed in the table, the building must be evaluated in accordance with the now current or greater seismicity of the region to be compliant with the RP 8 Standards.

SEISMIC FORM B - CERTIFICATE OF SEISMIC COMPLIANCE EXISTING BUILDING

The engineer shall evaluate the building to determine compliance with the Life Safety Performance Level. He or she shall use RP 8 Chapter 3 and ASCE/SEI 31 to determine compliance. The evaluation must include the appropriate Structural, Nonstructural, and Geologic Site Hazard and Foundation Checklists with backup calculations.

SEISMIC FORM C – BUILDING RETROFIT OR NEW CONSTRUCTION PRE-AWARD

COMMITMENT

Part 1 only applies to planned retrofit of an existing building. The Offeror shall identify the engineer in charge of the seismic retrofit and commit that the retrofit’s design and construction will conform to the requirements of ASCE/SEI 41, Basic Safety Objective.

The commitment must also include a Tier 1 report with supporting documentation, a narrative, scope, and schedule of the proposed renovations.

Part 2 only applies to new construction. The Offeror shall identify the engineer in charge of the design of the building and specify which building code he or she is using to design and construct.

Exhibit I

SEISMIC FORM D – OFFEROR’S REPRESENTATION OF EXEMPTION FROM SEISMIC

STANDARDS

The Offeror may claim an exemption from seismic compliance if representing that the offered building meets either of the following exemptions:

• In an area of moderate seismicity, the total space leased in the building by the Federal government, including the offered space, will be less than 10,000 ABOA SF upon commencement of the lease term.

• In an area of high to very high seismicity, the offered building is a one-story building of steel light frame or wood construction with less than 280 m2 (3,000

ABOA SF).

SEISMIC FORM E - CERTIFICATE OF SEISMIC COMPLIANCE RETROFITTED BUILDING

The engineer in charge of the building’s structural retrofit of the leased building shall certify that the design standard was the Basic Safety Objective as set forth in ASCE/SEI 41, Seismic Rehabilitation of Existing Buildings, and that the building was retrofitted to that standard.

SEISMIC FORM F - CERTIFICATE OF SEISMIC COMPLIANCE NEW BUILDING

The engineer shall certify that the design and construction of new buildings or additions to existing buildings conforms to the seismic provisions of the latest edition of the applicable State or local government codes under which it was built.

DEFINITIONS - The following definitions apply to the completion of the above-referenced forms:

1. Engineer means a professional engineer who is licensed in Civil or Structural Engineering and qualified in the structural design of buildings. They must be licensed in the state where the property is located.

2. ASCE/SEI 31 means the American Society of Civil Engineers standard, Seismic

Evaluation of Existing Buildings.” ASCE/SEI 31 can be purchased from ASCE at

(800) 548-2723, or by visiting http://www.pubs.asce.org.

3. ASCE/SEI 41 means American Society of Civil Engineers standard, Seismic

Rehabilitation of Existing Buildings.” ASCE/SEI 41 can be purchased from ASCE at (800) 548-2723, or by visiting http://www.pubs.asce.org.

4. Seismic Certificate means a certificate executed and stamped by an Engineer on the appropriate Certificate of Seismic Compliance form included with this solicitation together with any required attachments.

5. RP 8 means “Standards of Seismic Safety for Existing Federally Owned and Leased Buildings ICSSC Recommended Practice 8 (RP 8),” issued by the Interagency Committee on Seismic Safety in Construction as ICSSC RP 8 and the National Institute of Standards and Technology as NIST GCR 11-917-12.

You can obtain RP 8 from the Building and Fire Research Laboratory, National Institute of Standards and Technology, Gaithersburg, MD 20899, or download copy athttp://www.wbdg.org/ccb/NIST/nist_gcr11_917_12.pdf.

http://www.pubs.asce.org/ http://www.pubs.asce.org/

SEISMIC FORM A

CERTIFICATE OF SEISMIC COMPLIANCE

BENCHMARK BUILDING

Date: __________

This affirms that ________________________ served as engineer in charge of the seismic evaluation of the building located at ______________________________________________.

The building has the following characteristics:

ASCE Building Type: No. of Stories: Approx. Area:

Building Design Code: Year of Design Code: Year of Construction:

On the basis of the building characteristics and to the extent permitted by this level of evaluation, it is my opinion that the subject Building qualifies as a Benchmark Building as indicated in ASCE/SEI 31, Table 1-1.

Affix Stamp and Sign Here

Engineer’s Name:

Firm:

Address:

Telephone:

License No.:

License State:

Expiration Date:

SEISMIC FORM B

EXISTING BUILDING

This affirms that ________________________ served as engineer in charge of the seismic evaluation of the building located at ______________________________________________.

I have evaluated this building at the Life Safety Performance Level as set forth in the ICSSC RP 8, Standards of Seismic Safety for Existing Federally Owned and Leased Buildings, using ASCE/SEI 31 methodology:

___Tier 1 Evaluation

___Tier 2 Evaluation

___Tier 3 Evaluation

___Other (please explain below)

Documentation of this evaluation must be attached to this Certificate.

On the basis of the building characteristics and to the extent permitted by this level of evaluation it is my opinion that subject Building (check one) does / does not meet the Life Safety Performance Level of ICSSC RP 8.

Address:

Telephone:

License No.:

License State:

Comments:

Attach: ASCE/SEI 31 Checklist(s) Structural, Nonstructural, and Geologic Site Hazards and Foundation.

SEISMIC FORM C

BUILDING RETROFIT OR NEW CONSTRUCTION

PREAWARD COMMITMENT

PART 1

PREAWARD COMMITMENT TO RETROFIT BUILDING:

This affirms that _________________________ shall serve as the engineer in charge of the seismic retrofit of the building located at ________________________. The retrofit must be designed to meet the Basic Safety Objective, as set forth in ASCE/SEI 41 Seismic Rehabilitation of Existing Buildings.

In accordance with the requirements of this Standard and the seismic paragraph in the Request for Lease Proposals (RLP), our offer includes a commitment to retrofit the building to satisfy all of the Basic Safety Objective requirements of ASCE/SEI 41. The offer includes a Tier 1 report with all supporting documents, a narrative explaining the process, scope of renovations, and a schedule for the seismic retrofit.

Documentation shall be provided before award that demonstrates the seismic retrofit will meet the seismic standards and be completed within the time frame required.

PART 2

PREAWARD COMMITMENT TO CONSTRUCT A NEW BUILDING:

This affirms that _________________________ will serve as the engineer in charge of the structural design of the building located at ________________________. The criteria for design must be the ______ edition of the _____________________ building code.

In accordance with the requirements of this code, we prepared a quality assurance plan that included requirements for testing and inspecting critical elements of the structure and also periodic observation by our staff. We reviewed special inspection and testing reports prepared by the inspection agency and contractor submittals. On the basis of this, and to the extent permitted by this level of construction surveillance, it is my opinion that the Building was designed and constructed in conformance with the requirements of the above code.

Building Type: Building Height: Approx. Area:

OFFEROR

SIGNATURE NAME OF SIGNER

SEISMIC FORM D

OFFEROR’S REPRESENTATION OF EXEMPTION FROM SEISMIC STANDARDS

I represent that my building is exempt from the requirements of RP 8 because:

The Building is located in an area of medium seismicity and the…