(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 :