GSA12000
Prelease Fire Protection and Life Safety Evaluation for an Office Building
GSA Form 12000, Prelease Fire Protection and Life Safety Evaluation for an Office Building, is a General Services Administration form, Rev. 5/2011. GSA hosts it in its forms library.
The form says it has two parts, and which one applies depends on the floor where the proposed offered space is located. Part A applies to offered space below the 6th floor and is completed by the Offeror or their authorized representative. Part B applies to offered space on or above the 6th floor and is completed by a professional engineer. The Fundamental Code Requirements on the first page apply to both parts.
Part A is a series of short answer and yes, no or not applicable questions. Part B is a detailed narrative report based on an evaluation of the entire building. You can fill it out free in your browser on this page and download the result without an account.
The building is evaluated against the most recent building and fire code adopted by the jurisdiction, with egress evaluated under NFPA 101, Life Safety Code. A fire escape is not counted as an exit stair, and a scissor stair counts as one.
Building name and address with a 9-digit ZIP code, floors and square feet offered, floors above and below the street floor, reentry floors, and other uses such as restaurants, laboratories or a parking garage.
Yes, no or N/A questions on the automatic fire sprinkler system, fire alarm system, exit signs and emergency lighting, and elevators, plus space for additional information and the Offeror's Statement.
General information, including current citations, digital pictures of all sides of the building and hazardous fuel load areas, then occupancy classifications, building construction type and vertical openings.
Means of egress, including each exit stair, automatic fire suppression systems, the fire alarm system and elevators, with references to NFPA 25, NFPA 72, NFPA 110, NFPA 111 and ASME/A17.1.
The Statement of Fire Protection Engineer, with signature, printed name, firm, phone number, license number and stamp, and the Offeror's Statement of Correction.
The form says the number of floors is counted starting from the street floor. Part A covers offered space below the 6th floor, Part B space on the 6th floor or higher.
Check YES, NO or N/A for each question, describe the offered floors, then sign and date the Offeror's Statement.
The engineer writes a detailed narrative report on the entire building, including a review of the preventive maintenance records of the fire alarm and sprinkler systems.
The form says the report includes all deficiencies, the code references and recommended corrective actions. If none were found, the statement asks to say so explicitly.
The engineer's statement says the engineer initials each page and affixes an official seal, license information and signature.
The Offeror attests that work to bring the offered space into full compliance will be completed at the Offeror's sole cost and expense prior to the Government's acceptance.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
The PDF gives no filing address. It names the GSA Regional Fire Protection Engineering Office as the office that reviews Part B reports.
The form says an accepted GSA Form 12000, Part B is valid for 5 years from the noted date, on the condition that no major modifications or construction has occurred.
Reports submitted without the FPE's findings, recommended corrective actions and code references will be returned without review, the form says.
NFPA 101, NFPA 25, NFPA 72, NFPA 110, NFPA 111, ASME/A17.1 and the International Building Code.
The PDF prints no Privacy Act notice, OMB number or burden estimate.
GSA12002
33 fields, 1 page
GSA1204
24 fields, 1 page
GSA1364A
100 fields, 2 pages
GSA3518
48 fields, 10 pages
GSA3559B
10 fields, 1 page
The form names who completes, signs and reviews each part.
No tool matches that search.
The form is printed as a General Services Administration form, Rev. 5/2011. GSA hosts it in its forms library.
The form says Part A applies to offered space below the 6th floor and Part B to offered space on or above the 6th floor, counting floors from the street floor.
The form says a professional engineer licensed as a fire protection engineer in the same State as the building. Where a State does not formally recognize fire protection engineering, it says GSA will accept a professional engineer in that State who is recognized as a fire protection engineer in another U.S. State or Territory.
The form says 5 years from the noted date on the completed and accepted Part B, on the condition that no major modifications or construction has occurred.
The Offeror's Statement of Correction attests that the work to bring the space into full compliance will be completed at the Offeror's sole cost and expense prior to the Government's acceptance of the space.
The form says 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.
The form says a building with a Certificate of Occupancy showing full compliance with the International Building Code is deemed to comply with the code evaluation requirement.