Fire Alarm Isolation Permit - Form A

Form A Permit Number:

1. Details of proposed works CCAD Isolation Number:
Room/Corridor Name/ Number:
Building: Area: Department:

Level: Drawing attached: Yes / No

Fire Alarm Identification Numbers:

Date to start Isolation (D/M/Y): Time to start Isolation:

Date to end Isolation (D/M/Y): Time to end Isolation:
Description of work:

Systems to be worked on (Smoke / Heat detectors, Duct Detector, Pull Station, Sounders/Flashers, Vesda, Fire suppression, Novec, MSFD, Door Access, Door Hold
Open Devices, Sprinklers, Kitchen Suppression System):

Control Measures Check List

Ventilation equipment required and provided? Yes / No Protection of fire alarm devices required? Yes / No
Access to and location of nearest fire alarm point known? Yes / No For prolong periods of isolation, notification to CCAD to carry out
Responsible person provided by contractor fire watch trained? Yes / No fire watch outside working hours is required(>8hrs)? Yes / No

Print Name: Signature: Date(D/M/Y): Time:

Organisation: Telephone Number:
2. Notification
People advised of work
Fire Command Centre (FCC) : Yes / No CCAD Electrical Manager: Yes / No Facilities Help Desk: Yes / No
Department Manager: Yes / No Serco ELV Manager: Yes / No Security Command Centre : Yes / No

3.Authorisation
Serco Representative

Print Name: Signature: Date(D/M/Y): Time:

CCAD Facilities Representative

Print Name: Signature: Date(D/M/Y): Time:

*No work to commense until sections 1,2,3 & 4 are completed

4. Commencement of Works
I understand that the works detailed in section 1 above can now commence and that work has been authorised for this purpose and must be
completed by the persons in section 1 alone.
The fire system must be returned to an operable state by 16:30 today or as stated in the section 1.
Print Name: Signature: Date(D/M/Y): Time:
On completion of section 3 work can now commence.
All work must stop if required to do so.
The sounding of the fire system may invalidate this permit. Seek advice from the Permit user.

5. Completion / Suspension of works

All work associated with this permit has now been completed / suspended and all persons under my charge has been advised accordingly. No
further work will be carried out without issue of a new permit.

Work area has been checked and the fire system is fully operable: Yes / No
(a) Fire Alarm reinstated : Yes / No
(b) All faults clear: Yes / No
(c) System is back to normal : Yes / No
(d) All warning notices have been removed : Yes / No
(e) All persons detailed in section 2 have been notified that the system has been reinstated :Yes / No

Notes:

Print Name: Signature: Date(D/M/Y): Time:

6. CCAD Facilities Representative permit sign off
Print Name: Signature: Date(D/M/Y): Time:
Revision 00
Fire alarm isolations to be submitted a minimum of 48 hours prior to isolations being required. 10th June 2015
At the end of this permit the devices will be de-isolated and made active