(2019.
6)
FIRE PROTECTION IMPAIRMENT PERMIT
Requestor (Employee) : Requestor Phone Number : Today Date :
Building Name : Location/Room :
Contractor/Organization/Name : Phone Number :
Reason of Impairment : Work Order Number :
Requested Date of Impairment : Requested Time of Impairment :
Requested Date of Restored : Requested Time of Restored :
Fire Protection Systen Impaired (Check all that apply)
□ Fire Alarm System □ Detection System □ Automation Sprinkler System
□ Standpipe and Hose System □ Underground Piping&control Valve □ Fire Pumps
□ Water supply □ Special Suppresion System □ Others ____________________
Comments :
Authorized Signature : Date :
(Factory Manager)
Required Impairment Checklist :
□ Notify SHO □ Notify Factory Manager : □ Notify ERT
□ Hot Work Permit (If required) □ Fire Watch Established(If required) □ Removed Fire Alarm/Devices
□ Impairment Permit Posted : □ Lockout/Tagout Reviewed □ Hazardous Operation Stopped
Actual Start Date :_________________Time : ________________End Date :_____________Time :______________
Person(s) Performing Work (Print Names) :_________________________________________________________
_____________________________________________________________________________________________
Required Restoration Checklist :
□ Notify SHO □ Notify Factory Manager : □ Notify ERT
□ Remove Impairment Permit : □ Person In Charge
□ Activate Fire Alarm/Devices □ All mechanical devices in service (locked back in proper position)
SEND COMPLETED FORMS TO SAFETY & HEALTH OFFICER
NOTIFICATION OF FIRE PROTECTION
IMPAIRMENT FORM
Section A- to be completed by the Insured
Insured Name :
Location/Site Address :
System Impaired : □ Smoke Detectors □ Alart Connection □ Fire Pumps
□ Alarm Panel □ Thermal Detectors □ Water Supply
□ Sprinklers □ Hydrants □ Others :
Description of Impairment :
Reason of Impairment :
Impairment Start Date : Time :
Impairment End Date : Time :
Impairment Reported By :
Name :
Title :
Email :
Please indicate the precaution by local management below :
fire brigade notified? □ N/A □ Yes □ No
Manager and/or supervisors in charge in the impaired area notified? □ N/A □ Yes □ No
Is the impaired area monitored by heat/smoke detection system? □ N/A □ Yes □ No
Are additional fire extinguishers available in the impaired are? □ N/A □ Yes □ No
Hose reel system operational in the impaired area? □ N/A □ Yes □ No
Are additional security patrols or fire watch in place? □ N/A □ Yes □ No
Have hazardous operations such as hot work been discontinued? □ N/A □ Yes □ No
Additional Precautions/Comments :
Section B- to be completed by Willis Tower Watson
Additional Recommended Actions :
Submitted by :
Date :
Section C- to be completed by the insured once Fire Protection System are Restored
Date System Restored :
Restoration Notified By :
