Atch 20 Fire-Smoke Barrier Permit.doc

Department of Veterans Affairs

Memorandum 626-13-138-73 VA Tennessee Valley Healthcare System March 31, 2013

FIRE WALL AND SMOKE BARRIER PENETRATIONS

1. PURPOSE: To establish procedures regarding penetrations in ceilings, floors, pipe chases, fire walls, and smoke barriers for the purpose of maintaining the integrity of these structures as required by National Fire Protection Agency (NFPA) 101 and The Joint Commission to provide for the safety of occupants during fire incidents.

2. POLICY: All penetrations made in floors, ceilings, fire barriers, and smoke partitions for the purpose of installing/removing pipe, conduit, cable, or 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 or a temporary barrier shall be used at the end of a work period if the repairs have not been completed. This policy applies to all vertical and horizontal penetrations and to all Department of Veterans Affairs Tennessee Valley Healthcare System (VA TVHS) staff and contractors.

3. DEFINITIONS:

a. Penetration: Any hole, opening, or fault created in a fire barrier or smoke partition that compromises the integrity or fire rating of the penetrated structure.

b. Fire stopping material: Material used to replace or repair any penetrations. Material must meet specifications to ensure the original integrity and rating of the penetrated surface is restored.

c. Fire barriers: Floor, ceiling assemblies, and walls, including supporting construction that meets the conditions of acceptance of NFPA 251. Fire barriers are designed to form fire compartments and 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. RESPONSIBILITIES:

a. Service Chiefs must be knowledgeable of the requirements of this guideline with respect to equipment installations or modifications that are coordinated within their assigned building spaces.

b. Safety and Occupational Health Staff will:

(1) Issue “Fire/Smoke Barrier Penetration” permits to VA TVHS staff and contractors.

(See Attachment A)

(2) Inspect and approve all completed work. This shall be done in conjunction with the Project Engineers, if indicated.

c. Project Engineers, Contracting Officer’s Representatives (CORs), Information Management Service and other staff coordinating or performing such work are responsible for compliance with this guideline.

5. PROCEDURES:

a. A Fire/Smoke Barrier Penetration permit is obtained from the VA TVHS Safety Section; the permit will be assigned a specific case number. The permit shall be available for inspection at the designated site(s).

b. Prior to installation of equipment, cables, power connect, conduit, etc., all work, including Information Resource Management projects, will be approved by the Safety Section, Project Engineers, or delegates. This will include a review of the location and scope of work with the individual(s) performing the project.

c. The penetration, after installation or modification of the barrier, must be repaired (sealed) according to accepted practice and utilizing approved materials.

d. Upon completion of any penetration repair, a visual inspection for approval must be requested from the Project Engineer (if related to an Engineering project) or Safety personnel.

e. The completed permit will be signed by the user/responsible person(s) and Safety staff. Records shall be maintained in Engineering Service.

6. REFERENCES:

a. NFPA Life Safety Code 101, Chapter 8

b. NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction

c. VA Tennessee Valley Healthcare System, Memorandum 626-10-138-29 "Fire Safety/Life Safety Management Program"

7. RESCISSION: TVHS Memorandum 626-10-138-73 dated April 26, 2010.

8. RESPONSIBILITY AND REVIEW DATE: This memorandum will be reviewed annually by the Chief, Engineering Service and will be reissued no later than April 30, 2016.

/s/ Juan A. Morales, RN, MSN 6/17/2013

Juan A. Morales, RN, MSN Health System Director Attachment: A Distribution: Safety Manual

ATTACHMENT A

FIRE WALL/SMOKE BARRIER PENETRATION PERMIT

Contractor/VA Service _________________________________________________

Responsible Person ___________________________________________________

Telephone number/Email ______________________________________________ Case # Assigned __________

Location of work (building, floor, room number) ____________________________

Scope of work ________________________________________________________

Materials used:

Firestopping __________________________________________________________

Wall board ____________________________________________________________

Other ________________________________________________________________

Approving Official and Title

Date

Upon completion of work, a representative from TVHS Safety staff will visually inspect the area to ensure compliance with requirements.

Inspected by _____________________________ Date ______________________

Contractor/VA staff signature ___________________________________________ Comments ___________________________________________________________

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