J-1502000-02(DHA)-01_Above Ceiling Penetration Permit.pdf

ABOVE CEILING, FIRE AND SMOKE BARRIER PENETRATION PERMIT

Permit Number: ___________________________ Issue Date: ___________________

Approved by: Estimated Completion Date: ______________________

(Facilities Representative)

Permit Issued To:

(Department / Contractor Name) (Individual’s Name) (Phone Number)

Location of Corridor Wall(s) or Barrier(s) to be Penetrated: (building, floor, room number) (Attached Sketch if applicable) (Attached photos of existing condition of wall pentetrations if applicable)

Reasons for Penetration or Work to be Performed:

Final Inspection by Department/Contractor:

Sign: __________________________________________ Date: ______________________

Facilities Management:

Sign: __________________________________________ Date: ______________________

Instructions:

1. Maintain a copy of this permit at the work area at all times.

2. Promptly repair penetration in an approved (NFPA/MFG/CDC/etc…) manner. Contact the hospital’s Facilities

Management office, if there are any questions regarding the repairs.

3. Notify Facilities Management when repairs are complete to schedule a final inspection.

4. Contractors must fill all penetrations with a rated fire stopping product approved by the hospital.

5. Prior to performing related tasks within patient care, laboratory, surgery or other areas where the services rendered are directly impacting patient care; you will be required to obtain an Infection Control Permit.

6. All ceiling tile(s) will be reinstalled or replaced to the satisfaction of the final inspection.

7. Pictures will be taken of the fire and smoke barrier walls before the penetrations are made by department/contractor performing work. Pictures will be taken after the work has been completed by department/contractor performing work. Pictures will be sent to the Facilities Management office.

Pictures required for this permit? Yes No

NAVAL HOSPITAL, GUANTANAMO BAY, CUBA

POLICY AND PROCEDURE

SUBJECT: ABOVE THE CEILING INSTALLATION PERMIT PROGRAM

POLICY STATEMENT:

The above the ceiling permit program is designed to ensure the integrity of fire rated walls, doors and smoke compartments through the use of monitoring; inspecting and providing a permit to all outside contractors or subcontractors, and hospital personnel that may be creating penetrations.

PROCEDURE:

1. Each maintenance, telecommunications, I.T./MID, and contract employee shall submit a schedule of anticipated penetrations to Facilities Management Department (FMD) prior to the start of any construction project. All outside contractors and any Naval Hospital employee doing above ceiling work will be required to obtain a permit from the Facilities Management Department (FMD) before work begins.

2. The location of each penetration will be identified on a floor plan for the area under construction, and submitted to FMD.

3. Upon submission of all required documentation, an "Above Ceiling Installation Permit" will be issued to the contractor by FMD.

4. FMD will accompany the contractor to the construction site and will post the permit in a visibly prominent location, and the permit will remain posted for the duration of the project.

5. Upon completion of the permitted project, the contractor will notify the FMD that the project is complete and ready for inspection. Once inspected, FMD will sign off on the construction project.

6. No payment to any construction contractor will be allowed without documentation of a completed Above the Ceiling Installation Permit, signed by FMD and a completed Letter of Conformance signed by FMD.

LETTER OF CONFORMANCE

Project Name: _________________________________________________________________

Job Location: __________________________________________________________________

Brief Description of Job: __________________________________________________________

Firestop Manufacture Used: ______________________________________________________

I, _______________________ of _____________________, on this Date _______________, by completing and signing this letter certify that all firestop systems used on this project have been installed in accordance with Naval Hospital Guantanamo Bay, Cuba guidelines.

In addition, all firestop systems have been installed to system details and written instructions in accordance with UL 1479 / ASTM E 814 and/or UL 2079 / ASTM E 1966 test Standards.

The following supporting document s must be attached:

Approved UL or OPL systems used on the Job (may differ from initial permit)

Any Engineering Judgments provided for this project.

Signed, completed Above Ceiling Installation Permit (necessary for payment, if applicable)

Contractor Signature FMD Signature

Contractor Name (printed) FMD Representative (printed)

Date Date