Attachment K - VALBMC Above The Ceiling and Penetration Permit.pdf

VA Long Beach Healthcare System (VALBHS)

Above the Ceiling & Penetration Permit This permit requests must be submitted through the Fire & Life Safety PM, or Safety designee; 48 working hours in advance, before the start of any work. For emergency permit requests, call (562)826-8000 or ext. 3153.

Contact: VALBMC FLS PM Page 1 of 2 Form – FLS 5 (562)676-2236 or Ext. 3153 Rev: Sept. 2019 By: MB

Penetration - Life Safety Deficiency / ILSM Considerations

Horizontal or vertical penetrations, in: 1.) existing structure 2.) New construction

Smoke Barriers: YES NO Fire Barriers: YES NO

Will fire sprinklers, fire alarm system/devices be affected?................. YES NO

Will work have PACM (potentially asbestos containing material) exposure? …. YES NO

Other: ___________________________________________________________________________________

Acknowledgments/Approvals (print, sign, date):

General Contractor: ______________________________________________________ Date: __________________

*Acknowledges and is responsible for compliance with OSHA, IBR CONCENSUS STANDARDS and VHA requirement, for all work processes performed at VALBMC; and has read and understood reverse page information this permit.

1. Approved/Disapproved: _______________________________________________ Date: __________________

(Project Engineer: RE/COR)

2. Approved/Disapproved: _______________________________________________ Date: __________________

(Section Chief/Shop Supervisor)

3. Concur/Non-concur: __________________________________________________ Date: __________________

3.a Permit Expiration Date: _______________________________________________________________________

(Life Safety Officer)

Final, completion of work Inspection: ____________________________________________ Date: __________________

(COR)

Requestor: Date of Request: Date of Request:

COR/Requester’s HCG/Shop: Phone#:

Est. start of work – Date: Time: Est. Compl. of work -Date: Time:

Affected Working Area Building(s) #: HCG/Service/Clinic:

Floor(s): Room(s)#: Other:

Immediate Area Affected:

Scope/Description of work to Be performed:

Actual Start, Date/Time of work: / Actual Compl., Date/Time of work: /

Responsible Party for Sealing Penetrations Supervisor’s Name: Company:

Supervisors’ Phone#: 24-HR Emergency Phone#:

Type of penetration sealant or fire stop:

(submit/attach: SDS and/or applicable fire stop manufacture specification)

Type of penetration sealant or fire stop:

(submit/attach: SDS and/or applicable fire stop manufacture specification)

UL/ASTM Approved for use? Yes No (ex: ASTM E814, UL1479, etc.)

VA Long Beach Healthcare System (VALBHS)

Above the Ceiling & Penetration Permit This permit requests must be submitted through the Fire & Life Safety PM, or Safety designee; 48 working hours in advance, before the start of any work. For emergency permit requests, call (562)826-8000 or ext. 3153.

Contact: VALBMC FLS PM Page 2 of 2 Form – FLS 5 (562)676-2236 or Ext. 3153 Rev: Sept. 2019 By: MB

The VALBMC expectation is full cooperation in complying with our efforts to maintain our fire/smoke barriers, throughout our facility; and providing a safe environment for: our patients, staff, students, and visitors.

A. General contractors, vendors and VA staff performing short/long term work, that requires aspects of permit, at the VA Long Beach Healthcare System shall:

1) Obtain fully approved Above-Ceiling-Work/Fire/Wall Penetration Permit; prior to the commencement of any work.

2) Requests must be submitted 48 working hours prior to the start of any work. Permits are valid for 24 hours. On a case-by-case basis, the maximum length of any permit is 1 working week.

3) Must specifically include all work areas affected and thorough scope of work, for operation.

4) Ensure a copy of valid permits, are conspicuously posted at work location; and readily available for inspection/verification, upon request.

5) Permit must be accompanied by a completed and signed Infection Control Risk Assessment (ICRA) Form.

6) Upon completion of work and after COR’s final inspection. Permit is to be returned to the Safety Service’s

Fire and Life Safety PM to be filed: 1.). Permit, 2. JSA 3. SDS/MFG. Specifications.).

B. Permits shall be used to: 1.) Control, maintain and assure permanent record of any penetrations and/or drywall openings made in fire/smoke barriers. 2.) Ensure general safety precautions are addressed. Such as, but not limited to:

1) Secure the Area - placement of barricades or cones around work areas to prevent inadvertent access or exposure to all potential hazards associated with the scope of work to employees, patients, and visitors.

2) Not leave work area unattended - If work areas are left unattended for breaks or lunch, etc., ladders are stored safely, ceiling tiles are replaced, no wires, etc. are left in public access areas.

3) Securing the work tools and equipment so as not to create any hazard or be used as weapons.

C. General contractor scope of work shall include job specific Job Safety Analysis (JSA), to mitigate and address identified risk (ex: PACM, ILSM, Fall Protection, Electrical Safety, etc.). Attach JSA to permit request for VALBMC Fire & Life Safety Program Managers review.

D. General contractors, vendors are responsible for their employees, its agents or subcontractors; to be properly trained and knowledgeable on: 1.) The application of fire stopping materials. 2.) Scope of work. 3.) Applicable general safety, local policy & federal standards; and related environmental responsibility.

E. Within 24 hours or less, any penetrations made in a fire rated wall, ceiling, or floor; must be sealed.

Penetration seal work must be performed IAW applicable: manufacture specification, NFPA, consensus standard, and VA policy. The competed work must be visually inspected by the VA COR representative to verify integrity.

Under no circumstances will penetrations remain unsealed or open.

F. Please direct your questions to: Corresponding Engineering Contracting Officer Representative (COR), Project Engineer/designated representative, Unit Supervisor in charge of this project or the VA Life Safety Program Manger.