____________________Page 1 GSA FORM 12000 (May 2015)

PRELEASE

FIRE PROTECTION AND LIFE SAFETY EVALUATION FOR AN OFFICE BUILDING

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.

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PRELEASE

FIRE PROTECTION AND LIFE SAFETY EVALUATION FOR AN OFFICE BUILDING

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:

Restaurant Laboratories Storage Retail

Parking Garage

Other (list)

III. OTHER USES IN BUILDING (Check All T hat Apply)

IV. AUTOMATIC FIRE SPRINKLER SYSTEM

Please Check YES, NO, or N/A to the following questions: YES NO N/A

a. Is an automatic fire sprinkler system installed throughout the building?

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. Is a fire alarm system installed in the building?

b. Is an emergency voice/alarm communication system installed in the building?

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. 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. If a fire alarm system is installed in the building, is the fire alarm system over 25 years old?

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?

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VI. EXIT SIGNS EMERGENCY LIGHTING

Please Check YES, NO, or N/A to the following questions: YES NO N/A

a. Are exit signs installed in the paths of egress travel to the exit stairs or exits?

b. Is emergency lighting installed in the paths of egress travel to the exit stairs or exits?

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

Please Check YES, NO, or N/A to the following questions: YES NO N/A 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. ADDITIONAL 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:

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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.

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

vi. Any headeroom 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 Supression 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.

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PRELEASE

FIRE PROTECTION AND LIFE SAFETY EVALUATION FOR AN OFFICE BUILDING

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.)

Signature: Date:

Printed Name:

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.

Signature: Date:

Printed Name:

Title:

Name of Firm: