Attachment 8 - Replace Elevators 200 200E - Local Requirements.pdf

6.

Safety Management Section I, Chapter 9

March 5, 2012

Attachment

VAMC TOGUS

Confined Space Entry Permit

Location and Description of Confined Space ID #

Purpose of Entry Issuance Date/Time

Service/Department Completion Date/Time

Supervisor/Manager Attendant(s) Entrant(s) [Entry Log on Back]

Special Precautions YES NO (N/A) Special Precautions YES NO (N/A) Lockout/Tagout Full Body Harness Lines Broken/Capped/Blanked Tripod Inspected Portable Radio Used Safety Line Ventillation Required Fire Extinguisher Secure Area (cones, barricades) Employees Qualified Appropriate PPE Pre-Entry Briefing

Hot Work Permit Other_____________

Lighting Other ______________ Fire Department Notified YES/NO Signature of Approving Official _______________

Rescue Method: Entry_____ Non Entry_____

Tests Required Prior & During (Valid for Duration of Task)

Entry Prohibited If Following Exists:

Value & Time of Reading

Value & Time of Readin g

Value & Time of Reading

Value & Time of Reading

% of Oxygen <19.5% or >23.5%

% of LEL Any over 10%

Hydrogen Sulfide Over 10 ppm

Other All Sewer Entries Require Continual Monitoring

UNUSUAL CONDITIONS ADDITIONAL PRECAUTIONS

Monitor Used: PGD2_____ Other_____________ Calibration Date__________

FORM 16-2

Standard Pre-Lift Plan (LHE)/Checklist

Date: Job #: Location: _______________________

Time: Completed By (Competent Person): _____________________________

Note: Applies to Cranes, Derricks, Hoists and Power-Operated equipment that can be used to hoist, lower and/or horizontally move a suspended load (includes excavators, forklifts, Rough Terrain equipment, etc., when used with rigging).

Crane Considerations Yes No

1 Are the lifts within the crane’s rated capacities? (based on boom height, radius)

2 Boom deflections considered?

3 Have all potential crane boom obstructions been identified?

4 Have environmental considerations been addressed? (wind, weather, lightning)

5 Have electrical hazards been addressed (overhead /underground)

- Clearance distances established?

- Is a spotter required?

- Public Utility contact required?

6 Crane swing radius properly barricaded and personnel advised of hazards?

Comments:

Crane Considerations Yes No

1 Weights and Centers of Gravity (COG) have been determined?

2 Anything inside/outside the loads that could shift during the lift?

3 Does rigging need protection from the loads?

4 All anchor bolts, hold-downs, or fasteners have been removed?

5 Potential for binding: are load cells required to verify the loads are free?

6 Attachment points rated to take load weight?

7 Are the loads structurally capable of being lifted? (bending/twisting issues)

8 Is a Critical Lift Plan required per EM 385-1-1, Section 16.H?

Rigging Yes No

1 All rigging has been inspected by a Qualified Rigger?

2 Have sling angles been calculated?

3 Are shackles correctly sized for the sling eyes?

4 Are softeners needed?

Comments:

Personnel Yes No

1 The roles, responsibilities and qualifications for personnel have been defined?

(Operator, Lift Supervisor, Rigger, Signal Person)

2 A Pre-Lift meeting has been conducted?

3 Personnel trained per the EM?

Comments:

Area Preparation Yes No

1 The locations for the load landings has been selected and prepared?

2 Blocking and/or cribbing available to set the loads on?

3 Travel paths have been determined and cordoned off?

4 Other personnel in the area have been notified of the lifts?

5 Have ground bearing support questions been addressed?

Crane Operator: ___________________________________ Date: __________

Rigger(s): _________________________________________ Date: __________

Signal Person: ___________________________________ Date: __________

Other: _________________________________________ Date: ________

Weekly Construction Area Inspection Form

Weekly Construction Area Inspection Form

Date: __________ Contract Number or Description: _________________

Area or Building Name: ______________________________

Inspectors: ________________________________________

Please survey the work area and explain in Section B any deficiencies found.

Section A - Means of Egress YES NO N/A

1. Fire/smoke doors unlocked, free of obstructions?

2. Means of egress free of obstruction and clearly marked?

3. All Exits?

Section B - Fire Alarm, Fire Detection and Fire Suppression Systems

YES NO N/A

1. Fire alarm pull stations unobstructed? (If still in service)

2. Smoke detector dust caps in use (if still in service)?

3. Contractor employee assigned to ensure caps are removed at close of day?

4. Hot Work Permits in use?

5. Sprinkler heads unobstructed?

6. Heat detectors installed and in service?

Section C - Housekeeping and Traffic Control YES NO N/A

1. Trash and debris removed promptly?

2. Debris covered/dampened prior to being transported outside the construction area?

3. Floor mats and dust tack mats located at the entrance to the construction area and replaced as needed?

Section C - Housekeeping and Traffic Control YES NO N/A

4. Tool & material storage neat and orderly (18 inches below sprinkler heads)?

5. Signs installed to restrict patient access (doors locked as needed)?

6. Dry sweeping is not performed?

7. Doors closed, sheetrock or fire resistant plastic sheeting installed to enclose wall openings?

8. Barriers wiped down prior to being removed?

Section D - Air Handling and HVAC YES NO N/A

1. Negative pressure, with respect to the patient occupied space, is maintained within the construction area?

2. HVAC exhaust and supply ducts are covered during demolition?

3. Construction debris chutes are not adjacent to open windows or HVAC air intakes?

4. Other (list).

Section E - Hazardous Chemicals/Conditions YES NO N/A

1. Appropriate storage?

2. MSDS posted on job site?

3. Lockout/Tagout procedures in place?

4. Permit-required confined space procedures in place?

5. Hazardous building materials, such as asbestos, have been identified and addressed?

6. Other (list).

Section F - Clothing YES NO N/A

1. Contractor clothing are relatively dust free when performing work in a patient occupied space?

2. Contractors with dusty clothing are provided gowns and foot coverings when exiting through critical patient care areas?

3. Other (list).

Please explain nature of any non-compliance issues.

Section G - Non-Compliance Issues

Item # Deficiency Corrective Actions

Content of the above checklist is advisory and should be modified to satisfy the circumstances of the specific contract or work activity. Any modification of the checklist requires the consent of the safety and engineering staff.

Comments:___________________________________________________________________

This sheet to be posted at worksite

VA Maine Healthcare System Excavation Permit

Project Title & Number: Current Date:

VA COR/Project Lead: Contact Number:

VA Competent Person: Contact Number:

Contractor Supervisor: Contact Number:

Contractor Competent Person: Contact Number:

Soil Classification: Conducted by:

Excavation Start Date and Time:

Excavation End Date and Time:

Briefly describe scope, exact location, and dimensions of excavation project:

Contracted project: attach relevant drawings In-house project: attach sketch of proposed work

Contractor’s Supervisor signature VA COR/Project Engineer signature

Submit this sheet with signatures and completed Pre-Excavation Checklist to the VA Safety Manager.

VA Safety Manager signature Status (approved or not approved) Date

Pre-Excavation Checklist Check block for YES –or– line through if NOT APPLICABLE

� Surface encumbrances shall be removed or supported.

� The estimated location of utility installations in the vicinity shall be determined prior to starting excavation. Contact FMS at least 5 business days prior to starting excavation.

� When excavation operations approach the estimated location of underground installations, the exact location of the installations shall be determined by safe and acceptable means.

� While the excavation is open, underground installations shall be protected, supported or removed as necessary to safeguard employees.

� Structural ramps and runways that are used solely by employees as a means of access or egress from excavations shall be designed by a competent person.

� A ladder, ramp or other safe means of egress shall be located in trench excavations that are 4 feet or more in depth so as to require no more than 25 feet of lateral travel.

� Employees exposed to public vehicular traffic shall wear warning vests or other suitable garments marked with or made of reflective or high-visibility material.

� Employee shall NOT be permitted underneath loads handled by lifting or digging equipment.

� When mobile equipment is operated adjacent to an excavation, and the operator does not have a clear and direct view of the edge of the excavation, a warning system shall be utilized such as barricades, hand or mechanical signals, or stop logs.

� Adequate precautions shall be taken to prevent employee exposure to atmospheres containing less than 19.5 percent oxygen and other hazardous atmospheres.

� When controls are used to reduce the level of atmospheric contaminants to acceptable levels, testing shall be conducted as necessary to ensure that the atmosphere remains safe.

� Emergency rescue equipment shall be readily available (and attended when in use) where hazardous atmospheric conditions exist or may reasonably be expected to develop.

� Employees entering bell-bottom pier holes, or other similar deep and confined footing excavations, shall wear a harness with a life-line securely attached to it.

� Employees shall not work in excavations in which there is accumulated water, or in excavations in which water is accumulating, unless adequate precautions have been taken to protect employees against the hazards posed by water accumulation.

� If water accumulation is controlled or prevented by water removal equipment, the water removal equipment shall be monitored by a competent person to ensure proper operation.

� If excavation work interrupts the natural drainage of surface water, suitable means shall be used to prevent surface water from entering the excavation and adjacent areas.

� Excavations subject to runoff from rains require an inspection by a competent person.

� Where the stability of adjoining structures is endangered by excavation operations, support systems shall be provided to ensure the stability of such structures.

� Sidewalks, pavements, and appurtenant structure shall not be undermined unless a method of protection is provided to protect employees from the possible collapse.

� Excavation below the level of the base or footing of any foundation or retaining wall shall not be permitted except when:

- A support system is provided to ensure safety of employees and stability of the structure; or

- The excavation is in stable rock; or

- A registered professional engineer has approved the determination that the structure is sufficiently removed so as to be unaffected by the excavation activity; or

- A registered professional engineer has approved the determination that such excavation work will not pose a hazard to employees.

� Adequate protection shall be provided from loose rock or soil that could pose a hazard by falling or rolling from an excavation face.

� Materials or equipment that could fall or roll into shall be placed or kept at least 2 feet from the edge of excavations, or restrained by retaining devices, or by a combination of both.

� If a hazardous condition is identified then exposed employees shall be removed from the hazardous area until the necessary precautions have been taken to ensure their safety.

� Walkways shall be provided where employees or equipment are required or permitted to cross over excavations. Guardrails shall be provided where walkways are 6 feet or more above lower levels.

� Daily inspections of excavations are required prior to the start of work, as needed throughout the shift, and after every rainstorm or other hazardous event.

� Each employee in an excavation shall be protected from cave-ins by an adequate protective system except when excavations are made entirely in stable rock or are less than 5 feet in depth with no indication of a potential cave-in.

� Protective systems shall have the capacity to resist without failure all loads that are intended or could reasonably be expected to be applied or transmitted to the system.

� The slopes and configurations of sloping and benching systems shall be selected and constructed by the employer or his designee in accordance with 29 CFR 1926 Subpart P.

� Excavation designs shall be in written form and shall include a plan indicating the sizes, types, and configurations of the materials to be used in the protective system; and the identity of the registered professional engineer approving the design.

� Materials and equipment used for protective systems shall be free from damage or defects that might impair their proper function.

� Manufactured materials and equipment used for protective systems shall be used and maintained in a manner consistent with the recommendations of the manufacturer.

� When material or equipment that is used for protective systems is damaged, a competent person shall examine it and evaluate its suitability for continued use.

� Members of support systems shall be securely connected together to prevent failure.

� Support systems shall be installed and removed in a manner that protects employees from cave-ins, structural collapses, or from being struck by members of the support system.

� Before temporary removal of individual structural members begins, additional precautions shall be taken to ensure the safety of employees

� Removal shall begin at, and progress from, the bottom of the excavation. Members shall be released slowly so as to note any indication of possible failure of the remaining members of the structure or possible cave-in of the sides of the excavation.

� Backfilling shall progress together with the removal of support systems from excavations.

� Excavation of material to a level no greater than 2 feet below the bottom of the members of a support system shall be permitted, but only if the system is designed to resist the forces calculated for the full depth of the trench, and there are no indications while the trench is open of a possible loss of soil from behind or below the bottom of the support system.

� Installation of a support system shall be coordinated with the excavation of trenches.

� Shield systems shall not be subjected to loads exceeding those which the system was designed to withstand.

� Shields shall be installed in a manner hazardous movement of the shield in the event of the application of sudden lateral loads.

� Employees shall be protected from the hazard of cave-ins when entering or exiting the areas protected by shields.

� Employees shall not be allowed in shields when shields are being installed, removed, or moved vertically.

� Excavations of earth material to a level not greater than 2 feet below the bottom of a shield shall be permitted, but only if the shield is designed to resist the forces calculated for the full depth of the trench, and there are no indications while the trench is open of a possible loss of soil from behind or below the bottom of the shield.

Daily Inspection of Trenches and Excavations Date:

Project:

Weather:

Soil type:

Type of protective system:

Comments (describe any changes from previous daily inspection):

Shall be completed daily and when new hazards are introduced to excavation site.

Completed checklist shall be posted at worksite.

Excavation � Excavations and Protective Systems inspected by Competent Person daily, before start of work.

� Hard hats worn by all employees.

� Walkways and bridges over excavations 6' or more in depth equipped with guardrails.

� Warning vests or other highly visible PPE provided and worn by all employees exposed to vehicular traffic.

� Employees prohibited from working or walking under suspended loads.

� Work prohibited on faces of sloped or benched excavations above other employees.

� Warning system established/used when mobile equipment is operating near edge of excavation.

Utilities

� Underground installations protected, supported, or removed when excavation is open.

Wet Conditions

� Inspection made after each rainstorm by competent person

� Precautions taken to protect employees from accumulation of water.

� Surface water controlled or diverted.

Hazardous Atmosphere

� Ventilation provided to prevent flammable gas build-up to 20% of lower explosive limit of the gas if required

� Emergency Response Equipment readily available where a hazardous atmosphere could or does exist.

Signature of Competent Person: Date:

Department of Veterans Affairs Medical Center Togus Fire Department (ext. 5293)

Hot Work Permit

Hot Work Permit # 4373

Date Permit Issued: 3/5/2014 Date Permit Expires: 3/5/2014 Time: 7:41:04 AM

Service: Fill in Service here.

Building: 200 Location: Fill Location in here

Soldering Welding Grinding Cutting

By signing this form you acknowledge the precautions listed above have been met and the procedures and responsibilities are understood by all personnel involved in the hot work being performed.

Prior to conducting hot work the following precautions must be accomplished

A Fire Extinguisher must be available and deployable within 15 seconds of any accidental fire.

All loose combustible materials shall be cleared of the area where the hot work is being performed.

The area shall be well ventilated and free of any combustible gasses or dust.

The hot work shall be conducted only by qualified personnel and shall be limited to which was approved on this permit. Any deviation from the approved hot work being performed shall require an application for a new hot work permit.

Personnel conducting the hot work shall understand the requirements of this permit prior to conducting any hot work.

Signature of Operator, Contractor, Supervisor

Signature of Fire Department Representative issuing permit

In the situation where hot work is being performed in close proximity of combustible materials that cannot be removed, all necessary precautions shall be taken to ensure that the combustible material is protected from the hot work being performed or the work shall not be performed.

In the event hot shavings from grinding, cutting, soldering, etc. could be thrown or drop from the area of the hot work, precautions shall be taken to ensure that they cannot enter any crevices or holes were a fire extinguisher could not easily reach.

14 -

Operation to be Performed:

If smoke is being generated by the hot work, have the fire department remove any smoke detectors that are in the vicinity to avoid activation of the fire alarm.

Wednesday, March 05, 2014 Page 1 of 1

Appendix: Identify and communicate the responsibility for project monitoring that includes infection control concerns and risks. The ICRA may be modified throughout the project.

Revisions must be communicated to the Project Manager.

INFECTION CONTROL CONSTRUCTION PERMIT

Permit No:

Location of Construction: Project Start Date:

Project Coordinator: Estimated Duration:

Contractor Performing Work Permit Expiration Date:

Supervisor: Telephone:

YES NO CONSTRUCTION ACTIVITY YES NO INFECTION CONTROL RISK GROUP

TYPE A: Inspection, non-invasive activity

GROUP 1: Low Risk

TYPE B: Small scale, short duration, moderate to high levels

GROUP 2: Medium Risk

TYPE C: Activity generates moderate to high levels of dust, requires greater 1 work shift for completion

GROUP 3: Medium/High Risk

TYPE D: Major duration and construction requiring consecutive work shifts

GROUP 4: Highest Risk

CLASS I

1. Execute work by methods to minimize 3. Minor Demolition for Remodeling raising dust from construction operations.

1. Immediately replace any ceiling tile dis-placed for visual inspection.

CLASS II

1. Provides active means to prevent air-borne 6. Contain construction waste before transport in dust from dispersing into atmosphere. tightly covered containers.

2. Water mist work surfaces to control dust while 7. Wet mop and/or vacuum with HEPA filtered cutting. vacuum before leaving work area.

3. Seal unused doors with duct tape. 8. Place dust mat at entrance and exit of work area.

4. Block off and seal air vents. 9. Remove or isolate HVAC system in areas where

5. Wipe surfaces with disinfectant. work is being performed.

CLASS III

1. Obtain infection control permit before con- 6. Wet mop with disinfectant.

struction begins. 7. Remove barrier materials carefully to

2. Isolate HVAC system in area where work minimize spreading of dirt and debris is being done to prevent contamination associated with construction.

of duct system. 8. Contain construction waste before transport in

3. Complete all critical barriers or implement tightly covered containers.

control cube method before construction 9. Cover transport receptacles or carts.

Tape begins. covering.

4. Do not remove barriers from work area until 10. Remove or isolate HVAC system in areas where complete project is thoroughly cleaned by work is being performed.

Environmental Management.

5. Vacuum work with HEPA filtered vacuums.

Date:

Initial:

2.

CLASS IV

1. Obtain infection control permit before construction 6. Vacuum work area with HEPA filtered begins. 7. Wet mop with disinfectant.

2. Isolate HVAC system in area where work is being 8. Remove barrier materials carefully to done to prevent contamination of duct system. minimize spreading of dirt and debris

3. Complete all critical barriers or implement control associated with construction.

cube method before construction begins. 9. Contain construction waste before transport

4. Seal holes, pipes, conduits, and punctures in tightly covered containers.

appropriately. 10. Cover transport receptacles or carts.

Tape

5. Do not remove barriers from work area until covering.

completed project is thoroughly cleaned by 11. Remove or isolate HVAC system in areas the Environmental Management. where work is being done.

Additional Requirements:

Date: Initials: __________Exceptions/Additions to this permit.

Date: Initials: are noted by attached memoranda

Permit Request By: Permit Authorized By:

Date: Date:

Approved by Infection Control Date

Department of Veterans Affairs Environment of Care VA Maine Healthcare System Life Safety Management Augusta, Maine 04330 Section IV, Chapter 11

Attachment B

Interim Life Safety Measures (ILSM) Implementation Document

Project Title (if applicable): Project # (if applicable):

EFFECTS ON LIFE SAFETY:

Give brief description of the deficiency or project and the effects it will have on life safety that trigger the ILSM requirement.

PLAN OF ACTION:

The following Interim Life Safety Measures, if checked, will be implemented to compensate for the temporary hazards imposed during the project or until the deficiency is corrected:

1. Posting of signage identifying alternate exits. (Engineering)

a) Signs will be posted to identify alternate exit routes.

b) Areas where alternate signs have been posted will be inspected daily by the Contractor, Projects Section, and/or Safety Office using attachment C to ensure the posted signs remain in place and are appropriate.

2. Inspection of affected exits on a daily basis. (Safety Manager)

a) Affected exit routes will be inspected daily by the Contractor, Fire Department, Projects Section, and/or Safety Office using attachment C to ensure they are free and unobstructed.

3. Increase surveillance (Fire Department)

a) Construction areas will be inspected daily by the Contractor, Fire Department, Projects Section, and/or Safety Office using attachment C to ensure a high degree of safety is maintained.

Augusta, Maine 04330 Section IV, Chapter 11

4. Enforce storage, housekeeping, and debris removal. (Engineering)

a) Storage should be kept to a minimum and not pose any significant additional fire load or impede emergency egress.

b) Work areas should be cleaned up at least daily or more often, if conditions warrant.

c) Debris and waste should be removed from the building as often as practical to avoid clutter, but no less than daily.

d) Construction areas will be inspected daily by the Contractor, Fire Department, Projects Section, and/or Safety Office using attachment C to ensure a appropriate storage and housekeeping is maintained in the work area.

5. Provide temporary construction partitions. (Engineering)

a) Temporary partitions should be in accordance with NFPA 241.

b) Construction areas will be inspected daily by the Contractor, Fire Department, Projects Section, and/or Safety Office using attachment C to ensure temporary construction barriers are maintained.

6. Implement a Fire Watch. (Fire Department)

a) Notification to the fire department will be made whenever a total fire alarm or sprinkler systems is out of service for more than 4 hours in a 24 hour period. The time of this notification will be documented.

b) For construction projects, the Contractor or FMS will be responsible for providing the fire watch. The Fire watch will conduct rounds in the affected area(s) at approximately 30 minute intervals. Fire watch times will be documented.

c) Construction areas will be inspected daily by the Contractor, Fire Department, Projects Section, and/or Safety Office using attachment C to ensure a the fire watch is being completed and logs are maintained.

7. Provide temporary, but equivalent, fire alarm and detection systems.

(Fire Department)

a) Any temporary systems must be installed, inspected, tested, and approved by the Safety Office and or the Fire Department prior to removal of the existing system.

b) Construction areas will be inspected daily by the Contractor, Fire Department, Projects Section, and/or Safety Office using attachment C to ensure a these systems remain in place and monthly inspections are completed.

Augusta, Maine 04330 Section IV, Chapter 11

8. Inspect temporary systems monthly. (Fire Department)

a) Temporary systems will be inspected at least monthly. For construction projects, the contractor will be responsible for this inspection. Inspections dates will be documented.

9. Provide additional firefighting equipment. (Fire Department)

a) Construction areas will be inspected daily by the Contractor, Fire Department, Projects Section, and/or Safety Office using attachment C to ensure a the additional firefighting equipment is maintained.

10. Additional training for personnel on firefighting equipment.

(Fire Department)

a) Additional training will be provided to staff in the affected areas where additional firefighting equipment has been provided.

11. Additional fire drill per shift, per quarter. (Fire Department)

a) The Safety Office and or the Fire Department will ensure that additional drills are conducted in the area(s) affected as needed.

b) Egress route changes and/or closures of longer than 60 days will generally necessitate additional drills.

12. Train personnel to compensate for impaired structural or compartmentation features of fire safety. (Fire Department)

a) Personnel in area(s) will receive training by the Safety Office and or the Fire Department.

13. Conduct organization wide safety education programs to promote awareness of any Life Safety Code deficiencies, construction hazards, and ILSM measures. (Engineering)

a) Staff will be made aware of deficiencies, hazards, and interim measures in a weekly construction update via email and/or website.

Comments/Additional Information (reference ILSM Measure above):________________

ILSM Approved By:

Safety Manager

Fire Department

Contractor’s New Equipment Form

Equipment Name: ____________________________________

GENERAL CONTRACTOR’S NAME:___________________________

MANUFACTURER: _______________________________________

MODEL:_______________________________________________

SERIAL NUMBER: _____________________________________

LIFE EXPECTANCY [YEARS]:_____________________________

EQUIPMENT CATEGORY: _________________________________

P.O. [CONTRACT#] NO.:________________________________

VENDOR:______________________________________________

ACQ. DATE: [Install date] __________________________

WARRANTY EXPIRATION DATE:____________________________

LOCATION [Room/Building #]: _________________________

OWNERS/OPERATOR’S MANUALS SUPPLIED, (x4) Y N

COMMENTS(W):

Permit No: __________________ Date Valid: __________________

FIRE/SMOKE BARRIER PENETRATION PERMIT

A. General Rules and Regulations:

1. ALL PENETRATIONS/BREECHES MUST BE FILLED ON THE SAME DAY THEY ARE MADE.

2. U.L. APPROVED FIRE STOPPING MATERIALS MUST BE ON SITE PRIOR TO WORK. EACH SYSTEM TO BE USED

MUST BE APPROPRIATELY RATED FOR PENTRATION LOCATION.

3. THIS PERMIT IS VALID ONLY ON THE DATE OF ISSUANCE.

4. WHEN TEMPORARY FIRESTOPPING IS TO BE REMOVED FOR INSTALLATION OF PERMANENT SYSTEM A NEW

INSPECTION REQUEST MUST BE MADE FOR EACH PENETRATION.

5. CONTRACTOR/EMPLOYEE MUST REQUEST INPECTIONS AT THE END OF EACH WORK DAY ALLOWING

SUFFICIENT TIME TO ADDRESS DEFICIENCIES BEFORE LEAVING THAT DAY.

6. ANY PENETRATION IDENTIFIED BY THE FIRE DEPARTMENT AS NOT BEING LOCATED IN A FIRE/SMOKE

BARRIER MUST BE MADE SMOKE TIGHT.

B. To be filled out by Contractor/Engineering employee.

Date: ___________ Company/Dept: ____________________ Project Name/WO #: __________________________

Location of Penetration/Breech Building #:___________ Type of Firestopping System to be used: ______________________

Frm Rm # _______To Rm # _______ Dia. of Breech: ______Reason:________________________

Frm Rm # _______To Rm # _______ Dia. of Breech: ______Reason:________________________

Frm Rm # _______To Rm # _______ Dia. of Breech: ______Reason:________________________

Person Requesting Permit (Please Print):__________________________ Signature of Requestor: _________________________

Fire Department Use Only

C. Penetration identified as being in a Fire/Smoke Barrier: Yes____ No____

D. Number of breeches made through Fire Partition(s) ______ Smoke Partition(s) _____

Fire/Smoke Stopping Materials on site: Yes_____ No_____

Permit Approved By: _____________________ Title: ____________________

E. Upon completion of work, area has been inspected and all penetrations/breeches have been filled with U.L. approved fire stopping: Yes_____ No_____

Firestopping system identification shown at locations: Yes____ No____

Explain if not: _____________________________________________________________________________

Temporary Firestopping Inspected By: ______________________ Signature: ______________________ Date:_____________

Permanent Firestopping Inspected By: ______________________ Signature: ______________________ Date:_____________

PREVIOUS EDITION IS OBSOLETE.

MATERIAL APPROVAL SUBMITTAL

(See Instructions on Reverse)

TO: (Contracting Officer)

PROJECT NUMBER

FOR GOVERNMENT USE ONLY

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington VA 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Project OMB No 9000-0062, Washington DC 20503.

Please DO NOT RETURN your form to either of these addresses. Send your completed form to: SAF/AQCO, Pentagon, Washington DC 20330-1000.

FROM: (Contractor)

DATE

For Evaluation and Action

TO: (Base Civil Engineering Officer/ COR)

TYPE OR PRINT NAME AND GRADE SIGNATURE

TO: (AF Contracting Office)

RECOMMEND APPROVAL DISAPPROVAL AS INDICATED ABOVE AND SUBJECT TO ANY APPLICABLE COMMENTS ON THE REVERSE

APPROVED

DISAPROVED AS INDICATED ABOVE AND SUBJECT TO ANY APPLICABLE COMMENTS ON THE REVERSE SIDE. REQUEST

TO: (Contractor)

DATE TYPE OR PRINT NAME AND GRADE SIGNATURE

DATE

DATE TYPE OR PRINT NAME AND GRADE SIGNATURE

MODIFIED AF FORM 3000, SEP 91 (EF)

SUBMITTALSUBMISSION NUMBERCONTRACT NUMBER

NEW RESUBMITTAL

PREVIOUS SUBMISSION NUMBER

ITEM

NO.

SPECIFICATION SECTION/

PARA NO./DRAWING NO.

DESCRIPTION OF MATERIAL

(Include Type, Model Number, Mfg., etc. & file name of attachments)

SEE

REVERSE INITIAL

BY COMPLETING THIS FORM, THE UNDERSIGNED CONTRACTOR CERTIFIES THAT

THE MATERIAL COMPLIES WITH ALL SPECIFICATIONS OF SUBJECT CONTRACT.

AP-

PROVED

DISAP-

PROVED

TO BE COMPLETED BY CONTRACTOR

DATE TYPE OR PRINT NAME AND TITLE

SIGNATURE

FOR GOVERNMENT USE ONLY

Form Approved OMB No 9000-0062 Expires Apr 30, 1993

RESUBMITTAL ON DISAPPROVED ITEMS WITHIN DAYS OF DATE SHOWN BELOW.

A-E

VA Engineer/COTR

Contracting

COMMENTS

(Number to correspond with applicable Item Number on reverse)

INSTRUCTIONS TO CONTRACTORS

1. The term "material" is defined as articles, supplies, raw materials, equipment, parts, components, and end items that are to be incorporated into the work required by the contract.

2. This form is to be used by contractors for submitting Shop Drawings (*.DWG or *.PDF format), Manufacturer's Literature and Certificates (scanned as *.PDF) to the Government for approval in accordance with the provisions of this contract. Unless otherwise specified, it is to be prepared, signed, and E-mailed to the contracting officer with appropriate attachments. One paper format copy is to be submitted also.

3. Item(s) to be approved will be clearly tabbed or identified. Data pertaining to item(s) to be approved will be clearly identified or tabbed, particularly where documents are voluminous, in order to properly evaluate the materials or articles to be incorporated in the work. Each attachment will be numbered to correspond with the item number shown on the face of this form.

4. Requests submitted shall be numbered consecutively, by contract, in the space entitled "Submission No.". This number, in addition to the Contract No., will be used to identify each Material Approval Submittal. Resubmissions will be indicated in the appropriate block and the insertion of previous submission number and data in addition to a new submission number. A single submission should be used for all work of a section of the specifications, but in NO instance should the submission include work for more than one (1) contract. Submittals requiring priority handling will be submitted by separate submittal using the form and so marked across the face of the form.

5. This Material Approval Submittal is not valid unless it is signed by the contracting officer. This approval is required as called for by the contracting officer under the terms of this contract. One paper copy of the submittal is to be hand signed for Contracting Officers records.

MODIFIED AF FORM 3000, SEP 91 (E-MAIL FORMAT) (EF) (REVERSE)

Project Name: _______________ Type of Badge Requested: PIV NON-PIV FLASH Circle one

Department of Veterans Affairs VA Maine Healthcare System

Police Department 1 VA Center 07B

Augusta, ME 04330 207 623-5796

Last Name First Name Middle

Physical Street Address City State and Zip Code

Social Security Number

Gender (M) (F)

Service Line or Company Name Company or Cell Phone Number

Date of Birth

Place of Birth Occupation Title

Personal email for activation of badge process________________________________________________________

For Engineers to fill out:

Contract end date:_______________________________________________

Service Line Official Date

All highlighted info must be submitted, or a badge cannot be issued

FOR TOGUS POLICE USE ONLY

VISTA RECORDS:

DATE CHECKED BY RECORDS FOUND TYPE

VAPS RECORDS:

LOCAL RECORDS:

STATUS F YES NO ADVANCED TO HR

A MEMBER OF THE VA NEW ENGLAND HEALTHCARE SYSTEM

Contractor Outage Number:

Plumbing: Electrical: Med Gas: Fire Sprinkler: Other: _______

Phone:

Job Title:

Outage Request for: HVAC:

Date Outage Request Submitted:

Contractor:

Supervisor on Job Site:

Representative: Phone:

Building s , Level s , Block s , Department s , affected by this Outage:

escription to be performed start to finish (MOP)

IMPACT STATEMENT