ATTACHMENT 3 HI-Rise Form 12001.pdf

PRELEASE

FIRE PROTECTION AND LIFE SAFETY

EVALUATION FOR A HIGH-RISE OFFICE BUILDING

The offeror and the licensed fire protection engineer shall complete Parts A and B of this form. Part A consists of short answer and yes/no/not applicable questions related to the building's fire protection and life safety systems. Part B is detailed narrative report based on a walk-through of the building that includes the review of life safety system preventative maintenance records. The fire protection engineer shall prepare the detailed narrative report. The detailed narrative report and assessment of the building's features and life safety systems shall address at a minimum the items noted in Part B, Office Building Profile; as they apply to the offered building. In addition, the detailed narrative report shall include all deficiencies that do not meet the specified criteria with the associated code reference as well as recommended corrective action(s).

1. 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 National Fire Protection Association (NFPA) 101, Life Safety Code. All areas that do not meet the above stated criteria shall be identified as to the extent that they do comply.

2. Definition.

a. High-rise building: A building greater than 75 feet in height where the building height is measured from the lowest level of fire department vehicle access to the floor of the highest occupied floor. A building that is 6 stories or more in height is typically considered a high-rise building.

b. Hazards Area: Any space or compartment within a building in which storage or other activity exists that is not part of normal office space arrangements and that possesses the potential for producing a fully involved fire. Such areas used for: the storage or use of combustibles or flammables; toxic, noxious, or corrosive materials; or heat producing appliances, etc. (as defined in the latest edition of NFPA 101, Life Safety Code).

The offeror states, as part of this offer, that the proposed space/building is as described below and that information provided is accurate. In addition, the Offeror agrees all features and devices described below are in operating order and properly maintained. BOTH THE OFFEROR AND THE FIRE PROTECTION ENGINEER WILL MAKE THIS EVALUATION. THE FIRE PROTECTION ENGINEER'S OFFICIAL STAMP (PROFESSIONAL LICENSE) MUST BE PLACED ON BOTH PART A AND PART B. Please provide additional pages should this form not provide sufficient space to respond adequately to any question.

GENERAL SERVICES ADMINISTRATION GSA FORM 12001 (5/2005)PAGE 1 of 8

EVALUATION FOR A HIGH-RISE OFFICE BUILDING

PART A

BUILDING ADDRESS

Building Name:

Building Address:

City:

State:

9-Digit Zip Code:

BUILDING CODE AND FIRE CODE ADOPTED BY LOCAL JURISDICTION

SIZE AND LAYOUT

Building Code:

Fire Code:

YEAR:

YEAR:

The following information applies to (check one): an existing building a building planned for lease construction a building planned for lease construction with Government option to purchase

GENERAL SERVICES ADMINISTRATION GSA FORM 12001 (5/2005)PAGE 2 of 8

OTHER OCCUPANCIES IN BUILDING (Check All That Apply)

Identify each floor in which space is offered to Government:

BUILDING CONSTRUCTION TYPE (Check One)

VERTICAL OPENINGS (Check One)

ELECTRICAL SYSTEM

Identify gross square footage of space offered to Government on each floor:

Identify height (in feet) of the building above the lowest level of fire department vehicle access:

Identify the number of floors above the lowest level of fire department vehicle access:

Identify the number of floors below the lowest level of the department vehicle access:

Restaurants Laboratories Storage Retail Other (list)

Fire resistive Heavy Timber Ordinary Wood Frame Unprotective non-combustible

Between Two or More Floors

Exit Stairways

Shafts

Atrium

Other

None

Open Enclosed with doors, provide description

Enclosed, provide descriptionOpen

Enclosed, provide descriptionOpen

Enclosed, provide descriptionOpen

Enclosed, provide descriptionOpen

Please Check YES, NO, or NA to the following question: YES NO NA

The building electrical system appears to comply with the NFPA 70, National Electrical Code in that there are no obvious deficiencies (e.g., temporary wiring, use of extension cords, deteriorated equipment, missing equipment, etc.). If potential problems are noted, describe on an attached sheet.

EVALUATION FOR A HIGH-RISE OFFICE BUILDING

BUILDING EGRESS AND EXISTING SYSTEM

GENERAL SERVICES ADMINISTRATION GSA FORM 12001 (5/2005)PAGE 3 of 8

Please Check YES, NO, or NA to the following questions:

All exit doors swing in the direction of exit travel.

All exit stairways terminate directly at a public way or at an exterior discharge.

Exit access is at least 44 inches wide.

Corridors have a 1-hour fire-resistive rating.

Fire escapes are not counted as an approved exit.

Scissor stairs count as only one approved exit.

Unrestrictive access is provided to a minimum of two exists on each floor.

YES NO NA

NANOYES Please Check YES, NO, or NA to the following questions:

The travel distance to the exits is not more than 300 feet.

BUILDING NOT PROTECTED THROUGHOUT BY AUTOMATIC FIRE SPRINKLERS

The maximum length of a dead-end corridor is 50 feet.

The common path of travel is not more than 100 feet in length.

The minimum separation distance between two exits or exit access doors measured in a straight line between the exits or exit access doors shall not be less than one-third the length of the maximum overall diagonal dimension of the building or area served.

NANOYES Please Check YES, NO, or NA to the following questions:

The travel distance to the exits is not more than 200 feet.

The maximum length of a dead-end corridor is 50 feet.

The common path of travel is not more than 75 feet in length.

The minimum separation distance between two exits or exit access doors measured in a straight line between the exits or exit access doors shall not be less than one-half the length of the maximum overall diagonal dimension of the building or area served.

STANDPIPES AND PORTABLE FIRE EXTINGUISHERS

Standpipes are installed in building.

Portable fire extinguishers are installed in building.

Please Check YES, NO, or NA to the following questions: YES NO NA

BUILDING EXIT HARDWARE AND EGRESS DOORS

All exit stairway doors are in proper working order.

All exit stairway doors are self-closing or automatic-closing; and self-latching.

Please Check YES, NO, or NA to the following questions: YES NO NA

In an emergency, all exit stairway doors permit re-entry from the exit stairway enclosure to the interior of the building.

Exit doors require one action to open (e.g., no locks, locked during unoccupied period only).

NOTE: Special locking arrangements may be permitted if allowed by local jurisdiction.

BUILDING PROTECTED THROUGHOUT BY AUTOMATIC FIRE SPRINKLERS

EVALUATION FOR A HIGH-RISE OFFICE BUILDING

AUTOMATIC FIRE SPRINKLERS

GENERAL SERVICES ADMINISTRATION GSA FORM 12001 (5/2005)PAGE 4 of 8

Please Check YES, NO, or NA to the following questions:

Central Sprinkler Company's Omega line of fire sprinklers are installed in the building (describe location(s), model(s), number of sprinklers, date installed, etc. on additional sheet).

Automatic fire sprinklers are installed in other locations in the building (describe locations on additional sheet).

Automatic fire sprinklers are installed in all hazardous areas (as defined by NFPA 101, Life Safety Code).

Automatic fire sprinklers are installed only in corridors.

Automatic fire sprinklers are installed in all below-grade space.

Automatic fire sprinklers are installed throughout the building.

YES NO NA

Automatic fire sprinklers having an "O-Ring" are installed in the building (describe location(s), model(s), number of sprinklers, date installed, etc. on additional sheet).

The automatic fire sprinkler system is electronically supervised in accordance with NFPA 13, Standard for Installation of Sprinkler Systems.

The automatic fire sprinkler system is maintained in accordance with the applicable local codes or NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

SMOKE DETECTORS

Please Check YES, NO, or NA to the following questions:

Smoke detectors are installed in other locations in the building (describe other locations on additional sheet).

Smoke detectors are installed in all hazardous areas (as defined by NFPA 101, Life Safety Code).

Smoke detectors are installed only in elevator lobbies.

Smoke detectors are installed only in corridors.

Smoke detectors are installed throughout the building.

YES NO NA

Duct smoke detectors are installed in the building.

HEAT DETECTORS

Please Check YES, NO, or NA to the following questions:

Heat detectors are installed in other locations in the building (describe other locations on additional sheet).

Heat detectors are installed in all hazardous areas (as defined by NFPA 101, Life Safety Code).

Heat detectors are installed only in corridors.

Heat detectors are installed throughout the building.

YES NO NA

FIRE ALARM SYSTEM

Please Check YES, NO, or NA to the following questions:

Operation of the fire alarm system automatically notifies the local fire department or UL central station service.

Operation of the fire alarm system automatically notifies building occupants to evacuate or relocate within the building.

Visible alarm notification appliances are installed and located throughout the building.

Audible alarm notification appliances are installed and located throughout the building to be effectively heard above normal conditions of occupancy.

A fire alarm system is installed in the building.

YES NO NA

Emergency power is provided for the fire alarm system.

The fire alarm system has emergency voice communication capabilities.

The fire alarm system is maintained in accordance with the applicable local codes or NFPA 72, National Fire Alarm Code.

EVALUATION FOR A HIGH-RISE OFFICE BUILDING

HAZARDOUS AREAS

Hazardous Areas as defined by NFPA 101, Life Safety Code

Please Check YES, NO, or NA to the following questions:

List locations of all hazardous areas in the building (describe locations on additional sheet).

Hazardous areas are located in the building.

YES NO NA

GSA FORM 12001 (5/2005)PAGE 5 of 8GENERAL SERVICES ADMINISTRATION

EXIT SIGNS, EMERGENCY LIGHTING, & EMERGENCY POWER

Emergency lighting is installed along exit paths.

Illuminated exit signs are installed along exit paths.

Please Check YES, NO, or NA to the following questions:

Emergency power is provided for building's life safety systems (e.g., exit signs, emergency lighting, fire alarm, etc.)

An emergency generated is installed in the building to provide emergency power to the building's life safety systems.

An UPS system is installed in the building to provide emergency power to the building's life safety systems.

INTERIOR FINISH

Offered space has carpet installed on walls.

Offered space has corkboard installed on walls.

Please Check YES, NO, or NA to the following questions:

Offered space has wood paneling installed on walls.

ELEVATORS

Elevators are equipped with telephones or other two-way emergency signaling systems connected to an emergency communication location manned during normal working hours when the elevators are in service.

Elevators have a current certificate of elevator inspection from the local jurisdiction.

Please Check YES, NO, or NA to the following questions:

Elevators are automatically recalled by smoke detectors located in elevator lobbies and machine rooms.

Elevators recall to an alternate level when activated by primary level smoke detector.

Elevators are equipped with firemen's manual capture feature.

PUBLIC ADDRESS SYSTEMS

An independent public address system is provided throughout the building.

Please Check YES, NO, or NA to the following questions:

NANOYES

NANOYES

NANOYES

NANOYES

GSA FORM 12001 (5/2005)PAGE 6 of 8GENERAL SERVICES ADMINISTRATION

PART B

OFFICE BUILDING PROFILE

PRELEASE

FIRE PROTECTION AND LIFE SAFETY

EVALUATION FOR A HIGH-RISE OFFICE BUILDING

1. General Information.

a. Provide a copy of the certificate of occupancy issued by the local building official.

b. Identify any cited citations or violations noted by the local jurisdiction regarding the building.

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

d. Provide a scaled drawing(s) of the entire floor or floors in which space is being offered in the building. The scaled drawing(s) shall include the locations of all exit stairs and elevators. Indicate on the drawing the proposed space being offered to the Government.

e. Provide scaled drawings of the floor or floors where all exit stairs discharge.

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

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

h. Identify the proposed floors offered to the Government to occupy.

i. Identify by location and describe hazardous/significant fuel load areas that, when ignited, would produce significant adverse effects to its buildings and occupants.

j. Identify and describe potential fire ignition sources in hazardous/significant fuel load areas in the building. The proximity of the fuel source and the ignition source shall be described.

2. Building Construction.

a. Identify and describe the type of construction for floors, walls, columns, and roof of the building.

3. Occupancy Classifications.

a. Identify all the different types of occupancies on each floor of the subject building. Include mechanical equipment areas, storage areas, basement(s), etc.

b. Identify if the building is separated or non-separated mixed use and what fire rated separation is provided.

4. Vertical Openings.

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

b. Identify and describe the appropriateness of the firestop systems utilized in all penetrations of the enclosure of the vertical opening.

5. Means of Egresss.

a. Identify the number of exit stairs on each floor of the building. Interlocking (scissor) stairs count only as one exit stair.

b. Identify the number of fire escapes serving the building. Fire escapes shall not be counted as an approved exit.

c. For each exit stair, identify:

i. The clear width measurement between handrails.

ii. The location of where each exit stair discharges.

iii. If each exit stair enclosure allows re-entry from stair enclosure to the interior of the building.

iv. Describe all penetrations into and openings through each exit stair enclosure assembly.

v. Describe any headroom obstruction within each exit stair enclosure assembly.

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

vii. Exit stair remoteness.

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

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

f. Identify and describe if all fire doors are in proper working order.

g. Identify by floor and describe the exit access system (i.e., corridor or open plan office concept).

i. Describe the building's emergency lighting system.

GSA FORM 12001 (5/2005)PAGE 7 of 8GENERAL SERVICES ADMINISTRATION

FIRE PROTECTION AND LIFE SAFETY

EVALUATION FOR A HIGH-RISE OFFICE BUILDING

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

k. If emergency power for life safety systems is provided 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.

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 areas of the building where partial fire sprinkler protection is provided.

b. Identify and describe all areas within the building that are protected by different types of automatic fire sprinkler systems (e.g., dry, wet, pre-action, etc.,).

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 provided 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.

7. Fire Alarm System.

a. Identify and describe the age, type, manufacturer and model of fire alarm system.

b. Describe if the fire alarm system is connected to a U.L. listed Central Station Service or to the local fire department.

c. Describe in detail the operation of the fire alarm system.

d. Describe how the audible alarm notification appliances are installed and located throughout the building to be effectively heard above normal conditions of occupancy.

e. Describe if the fire alarm system has emergency voice communication capabilities.

f. Identify by location the installation of smoke detectors in the building.

g. Identify by location the installation of heat detectors in the building.

h. Identify by location the installation of duct smoke detectors in the building.

i. Identify and describe the HVAC fan shutdown features.

j. Describe in detail if the fire alarm system is tested and maintained in accordance with the applicable local codes or NFPA 72, National Fire

Alarm Code.

8. Interior Finish

a. Identify carpeting installed in any exit stairs and/or walls within the building.

9. Elevators.

a. Verifying the elevators have a current certificate 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 named during normal working hours when the elevators are in service.

GSA FORM 12001 (5/2005)PAGE 8 of 8GENERAL SERVICES ADMINISTRATION

FIRE PROTECTION AND LIFE SAFETY

EVALUATION FOR A HIGH-RISE OFFICE BUILDING

STATEMENT OF FIRE PROTECTION ENGINEER (FPE)

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 stamp, 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 reports.)

Signature:

Printed Name:

Name of Firm:

License Number:

Stamp Here:

Date:

Phone #:

OFFEROR'S STATEMENT OF CORRECTION

In the event any of offered space does not meet the above criteria, the Offeror shall attach a sheet describing the exact nature of the deficiency, and 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.

Signature:

Printed Name:

Title:

Date:

Name of Firm:

EVALUATION FOR A HIGH-RISE OFFICE BUILDING

The offeror and the licensed fire protection engineer shall complete Parts A and B of this form. Part A consists of short answer and yes/no/not applicable questions related to the building's fire protection and life safety systems. Part B is detailed narrative report based on a walk-through of the building that includes the review of life safety system preventative maintenance records. The fire protection engineer shall prepare the detailed narrative report. The detailed narrative report and assessment of the building's features and life safety systems shall address at a minimum the items noted in Part B, Office Building Profile; as they apply to the offered building. In addition, the detailed narrative report shall include all deficiencies that do not meet the specified criteria with the associated code reference as well as recommended corrective action(s).

1. 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 National Fire Protection Association (NFPA) 101, Life Safety Code. All areas that do not meet the above stated criteria shall be identified as to the extent that they do comply.

2. Definition.

a. High-rise building: A building greater than 75 feet in height where the building height is measured from the lowest level of fire department vehicle access to the floor of the highest occupied floor. A building that is 6 stories or more in height is typically considered a high-rise building.

b. Hazards Area: Any space or compartment within a building in which storage or other activity exists that is not part of normal office space arrangements and that possesses the potential for producing a fully involved fire. Such areas used for: the storage or use of combustibles or flammables; toxic, noxious, or corrosive materials; or heat producing appliances, etc. (as defined in the latest edition of NFPA 101, Life Safety Code).

The offeror states, as part of this offer, that the proposed space/building is as described below and that information provided is accurate. In addition, the Offeror agrees all features and devices described below are in operating order and properly maintained. BOTH THE OFFEROR AND THE FIRE PROTECTION ENGINEER WILL MAKE THIS EVALUATION. THE FIRE PROTECTION ENGINEER'S OFFICIAL STAMP (PROFESSIONAL LICENSE) MUST BE PLACED ON BOTH PART A AND PART B. Please provide additional pages should this form not provide sufficient space to respond adequately to any question.

GENERAL SERVICES ADMINISTRATION

GSA FORM 12001 (5/2005)

PRELEASE

FIRE PROTECTION AND LIFE SAFETY

EVALUATION FOR A HIGH-RISE OFFICE BUILDING

PART A

BUILDING ADDRESS

Building Name:

Building Address:

City:

State:

9-Digit Zip Code:

BUILDING CODE AND FIRE CODE ADOPTED BY LOCAL JURISDICTION

SIZE AND LAYOUT

Building Code:

Fire Code:

YEAR:

YEAR:

The following information applies to (check one):

an existing building a building planned for lease construction a building planned for lease construction with Government option to purchase

GENERAL SERVICES ADMINISTRATION

GSA FORM 12001 (5/2005)

OTHER OCCUPANCIES IN BUILDING (Check All That Apply) Identify each floor in which space is offered to Government:

BUILDING CONSTRUCTION TYPE (Check One) VERTICAL OPENINGS (Check One)

ELECTRICAL SYSTEM

Identify gross square footage of space offered to Government on each floor:

Identify height (in feet) of the building above the lowest level of fire department vehicle access:

Identify the number of floors above the lowest level of fire department vehicle access:

Identify the number of floors below the lowest level of the department vehicle access:

Restaurants Laboratories Storage Retail Other (list) Fire resistive Heavy Timber Ordinary Wood Frame Unprotective non-combustible Between Two or More Floors Exit Stairways Shafts Atrium Other None Open Enclosed with doors, provide description Enclosed, provide description Open Enclosed, provide description Open Enclosed, provide description Open Enclosed, provide description Open Please Check YES, NO, or NA to the following question:

YES

NO

NA

The building electrical system appears to comply with the NFPA 70, National Electrical Code in that there are no obvious deficiencies (e.g., temporary wiring, use of extension cords, deteriorated equipment, missing equipment, etc.). If potential problems are noted, describe on an attached sheet.

PRELEASE

FIRE PROTECTION AND LIFE SAFETY

EVALUATION FOR A HIGH-RISE OFFICE BUILDING

BUILDING EGRESS AND EXISTING SYSTEM

GENERAL SERVICES ADMINISTRATION

GSA FORM 12001 (5/2005)

Please Check YES, NO, or NA to the following questions:

All exit doors swing in the direction of exit travel.

All exit stairways terminate directly at a public way or at an exterior discharge.

Exit access is at least 44 inches wide.

Corridors have a 1-hour fire-resistive rating.

Fire escapes are not counted as an approved exit.

Scissor stairs count as only one approved exit.

Unrestrictive access is provided to a minimum of two exists on each floor.

YES

NO

NA

NA

NO

YES

Please Check YES, NO, or NA to the following questions:

The travel distance to the exits is not more than 300 feet.

BUILDING NOT PROTECTED THROUGHOUT BY AUTOMATIC FIRE SPRINKLERS

The maximum length of a dead-end corridor is 50 feet.

The common path of travel is not more than 100 feet in length.

The minimum separation distance between two exits or exit access doors measured in a straight line between the exits or exit access doors shall not be less than one-third the length of the maximum overall diagonal dimension of the building or area served.

NA

NO

YES

Please Check YES, NO, or NA to the following questions:

The travel distance to the exits is not more than 200 feet.

The maximum length of a dead-end corridor is 50 feet.

The common path of travel is not more than 75 feet in length.

The minimum separation distance between two exits or exit access doors measured in a straight line between the exits or exit access doors shall not be less than one-half the length of the maximum overall diagonal dimension of the building or area served.

STANDPIPES AND PORTABLE FIRE EXTINGUISHERS

Standpipes are installed in building.

Portable fire extinguishers are installed in building.

Please Check YES, NO, or NA to the following questions:

YES

NO

NA

BUILDING EXIT HARDWARE AND EGRESS DOORS

All exit stairway doors are in proper working order.

All exit stairway doors are self-closing or automatic-closing; and self-latching.

Please Check YES, NO, or NA to the following questions:

YES

NO

NA

In an emergency, all exit stairway doors permit re-entry from the exit stairway enclosure to the interior of the building.

Exit doors require one action to open (e.g., no locks, locked during unoccupied period only).

NOTE: Special locking arrangements may be permitted if allowed by local jurisdiction.

BUILDING PROTECTED THROUGHOUT BY AUTOMATIC FIRE SPRINKLERS

PRELEASE

FIRE PROTECTION AND LIFE SAFETY

EVALUATION FOR A HIGH-RISE OFFICE BUILDING

AUTOMATIC FIRE SPRINKLERS

GENERAL SERVICES ADMINISTRATION

GSA FORM 12001 (5/2005)

Please Check YES, NO, or NA to the following questions:

Central Sprinkler Company's Omega line of fire sprinklers are installed in the building (describe location(s), model(s), number of sprinklers, date installed, etc. on additional sheet).

Automatic fire sprinklers are installed in other locations in the building (describe locations on additional sheet).

Automatic fire sprinklers are installed in all hazardous areas (as defined by NFPA 101, Life Safety Code).

Automatic fire sprinklers are installed only in corridors.

Automatic fire sprinklers are installed in all below-grade space.

Automatic fire sprinklers are installed throughout the building.

YES

NO

NA

Automatic fire sprinklers having an "O-Ring" are installed in the building (describe location(s), model(s), number of sprinklers, date installed, etc. on additional sheet).

The automatic fire sprinkler system is electronically supervised in accordance with NFPA 13, Standard for Installation of Sprinkler Systems.

The automatic fire sprinkler system is maintained in accordance with the applicable local codes or NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

SMOKE DETECTORS

Please Check YES, NO, or NA to the following questions:

Smoke detectors are installed in other locations in the building (describe other locations on additional sheet).

Smoke detectors are installed in all hazardous areas (as defined by NFPA 101, Life Safety Code).

Smoke detectors are installed only in elevator lobbies.

Smoke detectors are installed only in corridors.

Smoke detectors are installed throughout the building.

YES

NO

NA

Duct smoke detectors are installed in the building.

HEAT DETECTORS

Please Check YES, NO, or NA to the following questions:

Heat detectors are installed in other locations in the building (describe other locations on additional sheet).

Heat detectors are installed in all hazardous areas (as defined by NFPA 101, Life Safety Code).

Heat detectors are installed only in corridors.

Heat detectors are installed throughout the building.

YES

NO

NA

FIRE ALARM SYSTEM

Please Check YES, NO, or NA to the following questions:

Operation of the fire alarm system automatically notifies the local fire department or UL central station service.

Operation of the fire alarm system automatically notifies building occupants to evacuate or relocate within the building.

Visible alarm notification appliances are installed and located throughout the building.

Audible alarm notification appliances are installed and located throughout the building to be effectively heard above normal conditions of occupancy.

A fire alarm system is installed in the building.

YES

NO

NA

Emergency power is provided for the fire alarm system.

The fire alarm system has emergency voice communication capabilities.

The fire alarm system is maintained in accordance with the applicable local codes or NFPA 72, National Fire Alarm Code.

PRELEASE

FIRE PROTECTION AND LIFE SAFETY

EVALUATION FOR A HIGH-RISE OFFICE BUILDING

HAZARDOUS AREAS

Hazardous Areas as defined by NFPA 101, Life Safety Code Please Check YES, NO, or NA to the following questions:

List locations of all hazardous areas in the building (describe locations on additional sheet).

Hazardous areas are located in the building.

YES

NO

NA

GSA FORM 12001 (5/2005)

GENERAL SERVICES ADMINISTRATION

EXIT SIGNS, EMERGENCY LIGHTING, & EMERGENCY POWER

Emergency lighting is installed along exit paths.

Illuminated exit signs are installed along exit paths.

Please Check YES, NO, or NA to the following questions:

Emergency power is provided for building's life safety systems (e.g., exit signs, emergency lighting, fire alarm, etc.)

An emergency generated is installed in the building to provide emergency power to the building's life safety systems.

An UPS system is installed in the building to provide emergency power to the building's life safety systems.

INTERIOR FINISH

Offered space has carpet installed on walls.

Offered space has corkboard installed on walls.

Please Check YES, NO, or NA to the following questions:

Offered space has wood paneling installed on walls.

ELEVATORS

Elevators are equipped with telephones or other two-way emergency signaling systems connected to an emergency communication location manned during normal working hours when the elevators are in service.

Elevators have a current certificate of elevator inspection from the local jurisdiction.

Please Check YES, NO, or NA to the following questions:

Elevators are automatically recalled by smoke detectors located in elevator lobbies and machine rooms.

Elevators recall to an alternate level when activated by primary level smoke detector.

Elevators are equipped with firemen's manual capture feature.

PUBLIC ADDRESS SYSTEMS

An independent public address system is provided throughout the building.

Please Check YES, NO, or NA to the following questions:

NA

NO

YES

NA

NO

YES

NA

NO

YES

NA

NO

YES

GSA FORM 12001 (5/2005)

GENERAL SERVICES ADMINISTRATION

PART B

OFFICE BUILDING PROFILE

PRELEASE

FIRE PROTECTION AND LIFE SAFETY

EVALUATION FOR A HIGH-RISE OFFICE BUILDING

1. General Information.

a. Provide a copy of the certificate of occupancy issued by the local building official.

b. Identify any cited citations or violations noted by the local jurisdiction regarding the building.

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

d. Provide a scaled drawing(s) of the entire floor or floors in which space is being offered in the building. The scaled drawing(s) shall include the locations of all exit stairs and elevators. Indicate on the drawing the proposed space being offered to the Government.

e. Provide scaled drawings of the floor or floors where all exit stairs discharge.

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

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

h. Identify the proposed floors offered to the Government to occupy.

i. Identify by location and describe hazardous/significant fuel load areas that, when ignited, would produce significant adverse effects to its buildings and occupants.

j. Identify and describe potential fire ignition sources in hazardous/significant fuel load areas in the building. The proximity of the fuel source and the ignition source shall be described.

2. Building Construction.

a. Identify and describe the type of construction for floors, walls, columns, and roof of the building.

3. Occupancy Classifications.

a. Identify all the different types of occupancies on each floor of the subject building. Include mechanical equipment areas, storage areas, basement(s), etc.

b. Identify if the building is separated or non-separated mixed use and what fire rated separation is provided.

4. Vertical Openings.

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

b. Identify and describe the appropriateness of the firestop systems utilized in all penetrations of the enclosure of the vertical opening.

5. Means of Egresss.

a. Identify the number of exit stairs on each floor of the building. Interlocking (scissor) stairs count only as one exit stair.

b. Identify the number of fire escapes serving the building. Fire escapes shall not be counted as an approved exit.

c. For each exit stair, identify:

i. The clear width measurement between handrails.

ii. The location of where each exit stair discharges.

iii. If each exit stair enclosure allows re-entry from stair enclosure to the interior of the building.

iv. Describe all penetrations into and openings through each exit stair enclosure assembly.

v. Describe any headroom obstruction within each exit stair enclosure assembly.

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

vii. Exit stair remoteness.

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

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

f. Identify and describe if all fire doors are in proper working order.

g. Identify by floor and describe the exit access system (i.e., corridor or open plan office concept).

i. Describe the building's emergency lighting system.

GSA FORM 12001 (5/2005)

GENERAL SERVICES ADMINISTRATION

PRELEASE

FIRE PROTECTION AND LIFE SAFETY

EVALUATION FOR A HIGH-RISE OFFICE BUILDING

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

k. If emergency power for life safety systems is provided 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.

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 areas of the building where partial fire sprinkler protection is provided.

b. Identify and describe all areas within the building that are protected by different types of automatic fire sprinkler systems (e.g., dry, wet, pre-action, etc.,).

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 provided 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.

7. Fire Alarm System.

a. Identify and describe the age, type, manufacturer and model of fire alarm system.

b. Describe if the fire alarm system is connected to a U.L. listed Central Station Service or to the local fire department.

c. Describe in detail the operation of the fire alarm system.

d. Describe how the audible alarm notification appliances are installed and located throughout the building to be effectively heard above normal conditions of occupancy.

e. Describe if the fire alarm system has emergency voice communication capabilities.

f. Identify by location the installation of smoke detectors in the building.

g. Identify by location the installation of heat detectors in the building.

h. Identify by location the installation of duct smoke detectors in the building.

i. Identify and describe the HVAC fan shutdown features.

j. Describe in detail if the fire alarm system is tested and maintained in accordance with the applicable local codes or NFPA 72, National Fire Alarm Code.

8. Interior Finish

a. Identify carpeting installed in any exit stairs and/or walls within the building.

9. Elevators.

a. Verifying the elevators have a current certificate 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 named during normal working hours when the elevators are in service.

GSA FORM 12001 (5/2005)

GENERAL SERVICES ADMINISTRATION

PRELEASE

FIRE PROTECTION AND LIFE SAFETY

EVALUATION FOR A HIGH-RISE OFFICE BUILDING

STATEMENT OF FIRE PROTECTION ENGINEER (FPE)

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 stamp, 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 reports.)

Signature:

Printed Name:

Name of Firm:

License Number:

Stamp Here:

Date:

Phone #:

OFFEROR'S STATEMENT OF CORRECTION

In the event any of offered space does not meet the above criteria, the Offeror shall attach a sheet describing the exact nature of the deficiency, and 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.

Signature:

Printed Name:

Title:

Date:

Name of Firm: