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Welcome to the Interim Fire and Life Safety Course for Contractors and Consultants. Jeff Combs Cleveland Clinic Fire Marshal 216-444-6617 Fax: 444-2419 Cell Phone: 216-312-9566 E-mail: CombsJ@ccf.org. So…why are we here?.

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welcome to the interim fire and life safety course for contractors and consultants

Welcome to the Interim Fire and Life Safety Course for Contractors and Consultants

Jeff Combs

Cleveland Clinic Fire Marshal

216-444-6617 Fax: 444-2419

Cell Phone: 216-312-9566

E-mail: CombsJ@ccf.org

so why are we here
So…why are wehere?
  • To review and acquaint CC contractors and consultants with requirements, guidelines and specific protocol while working at Cleveland Clinic facilities. Refresher required every 2 years.
  • Project Manager:All contractors will have a Cleveland Clinic project manager assigned to their project and should know who they are.
  • Job Board:All projects require job boards which should post all applicable permits, floor plan of project including location of sprinkler shut off valves, extinguishers, fire alarm boxes, exits, etc. Some jobs may be small. A clipboard will suffice for the job board in such cases.
permits permits permits
A. CRRAS-Construction & Renovation Risk Assessment Subcommittee

1.There are five possible types of fire permits that you may need to acquire:

a. Open burning

b. Hazardous substance

(City of Cleveland)

c. Fire retardant zipwall

d. Ceiling tile

e. Firestop penetration

Please call Tara at216-445-3438to set up an appointment for obtaining these. Appointments will be granted for 15 minutes


Permits, Permits, Permits!
hotwork open burning
Hotwork (Open Burning)
  • CC Contractors are required to obtain an Open Burning permit from CC Fire Marshal for use with any Open Flame device. Any open flame operation being performed without a permit, will be shutdown until the permit is secured. Requests for permits should be at least 24 hours in advance of the work performed.
hotwork procedures
Hotwork Procedures
  • Parties are responsible to call the Inspector daily no earlier than 7:00am. Please call 216-445-3432 and provide your name, company, location, permit number, a reliable contact phone number and the nature of the hotwork. When calling in hotwork, you must wait for pre-inspection before starting hotwork. CC Fire Marshal office reserves right to randomly inspect. Parties are also responsible for calling when ending hotwork, before 2:30pm, and must wait for post-inspection before leaving jobsite. Any exceptions must be approved by Cleveland Clinic Fire Marshal (Jeff Combs), and must be inspected by Cleveland Clinic Police before leaving jobsite. Unannounced site visits may occur, and citations may occur if not compliant. Please fax City of Cleveland Hazardous Substance permits to Cleveland Clinic Fire Marshal at 216-444-2419.
fire blankets
Fire Blankets

Fire blankets for hotwork will be FM approved. To the right is an example of the symbol representing FM Approval.

hazardous substances
Hazardous Substances
  • The Cleveland Fire Prevention and Building Code, section 385 Permit required, states that a permit is required by contractors for the use, storage, and handling of flammable gases, compressed gases and flammable liquids in quantities >= 5 lbs/ 5 gals as applicable . No size quantity for LPG.
  • Contractors will provide Material Safety Data Sheets (MSDS) at the job site for all Hazardous Chemicals used. Questions can be directed to the CC Hazardous Materials Coordinator at (216)444-6095.
common examples of hazardous substances
Common Examples of Hazardous Substances
  • Flammable Liquids: 5 lbs/5 gallons
    • Gas, Solvents, Alcohols, Mineral Spirits, Sealers, Aerosols, Paints, Glues.
  • Combustible Liquids: 5 lbs/5 gallons
    • Diesel, Solvents, Sealers, Paints, Glues.
  • Liquified Petroleum Gas: Any Quantity
    • Propane, Butane
  • Compressed Gases: 5 lbs/5 gallons
    • Oxygen, Argon, Nitrogen, Acetylene
fire retardant zipwall
Fire Retardant Zipwall
  • Only Fire retardant zipwall plastic is acceptable for ensuring that all temporary construction partitions are smoketight and non-combustible. It is not considered a fire barrier. Permit for this zipwall is required.


ceiling tile permits
Ceiling Tile Permits
  • If at anytime or place, any project work requires that a ceiling must be entered for any purpose the following protocol will be followed:
  • The following information will need to be available: Company, Requester, Workers, Reason to Enter, CC Project Manager, Project, Specific Area, How many tiles?, and how long the activity will take.
  • Permits must be available and displayed at all locations on site where tiles are out. Make many copies if needed. Posting permits on ladders is not permitted but only on all metal ceiling tile grid exposed.
firestopping permit
Firestopping Permit
  • Never firestop without a permit!!
  • Before firestopping, you must take a the 4-hour firestopping course. Call Tara at

(216)445-3438to register for class.

3 types of fire protection
3 Types of Fire Protection

1. Sprinklers

2. Smoke Detectors

3. Rated Barriers

firestopping mep
Firestopping MEP

2 Types:

1. Through

2. Membrane

background plans


a. Life Safety Drawing

b. UL# Firestop System for Joints


a. UL# Firestop System for Through/Membrane



a. Train

b. Certify

c. Assist

1. On site

2. Engineering Judgments


a. Trained

b. Certified

c. Do Homework

electronic firestopping instructions
Electronic Firestopping Instructions

1. Prepare electronic FSPP with table by filling in all required information. Information for the table will come from field contractor who filled it out by hand. (Sample on next slide)

2. Compile a list of UL# firestop systems from the table.

3. Go to website for STI etc to do a UL search athttp://sti.fmpdata.net/system_search.htmlor equivalent.

4. Acquire an electronic pdf for each system compiled and save in your computer.

5. Send and email to Cleveland Clinic Fire Marshal atcombsj@ccf.organd attach the filled out FSPP and all pdf’s compiled.

6. Once FSPP is received, make sure that workers in the field have a copy of the permit and all printed copies of pdf’s. Permits in the field without the printed pdf’s attached are considered non-compliant.

  • Contractors working only a few days maximum require the paper ID card which will be filled out completely.
  • Contractors who are working at CC for more than a few days are required to get a Temporary ID badge (plastic) from the Chester Conference Center. Attendance of this course mandatory for badge.
When working in any CC Patient Care Facility, Joint Commission for the Accreditation of Hospitals Interim Life Safety Measures will apply.

These are as follows:

ensuring that exits are free from obstruction
Ensuring that Exits are free from obstruction
  • The Fire Code will not permit exit capacity or condition to be reduced from original design levels.
ensuring that fire related alarm detection and suppression systems are not impaired
Ensuring that fire related alarm, detection, and suppression systems are not impaired:
  • In case of impairment, it will be the responsibility of the contractor to coordinate with CC Construction Management, CC Facilities Engineering, and Management companies to provide fire watch as required.
Bagging of smoke detectors is not permitted. Contact CC Construction Management, CC Facilities Engineering, and Management companies to initiate a shutdown of fire alarm devices.
  • Unnecessary Fire Alarms activated by contractors which lead to a City of Cleveland Fire Department fine will be backcharged to the contractor
to initiate shutdown please follow these procedures
To Initiate Shutdown, please follow these procedures:

1. The contractor requests shutdown from project manager.

2. Project manager initiates shutdown notice.

3. Cleveland Clinic Fire Marshal will approve/disapprove and provide conditions (ex: fire watch)

4. Facilities will initiate shutdown.

5. Facilities will communicate to contractor that the shutdown is accomplished.

6. Contractor will perform work.

7. Contractor will do fire watch as required.

8. Contractor will advise facilities when complete.

9. Facilities will turn back on.

10. Facilities will communicate to contractor that fire protection is back on.

11. The contractor, being relieved of fire watch, as applicable, is free to discontinue.

12. Contractor will fax fire watch in real time within 30 minutes of being advised of being turned back on to 216-444-2419.

3 conditions where fire watch is required even if fire sprinklers are still on
3 conditions where fire watch is required even if fire sprinklers are still on.

1. Smoke detectors shutdown in elevator lobbies.

2. Smoke detectors shutdown in smoke management systems.

3. Smoke detectors shutdown that control fire doors.

ensuring that all temporary construction partitions are smoketight and non combustible
Ensuring that all temporary construction partitions are smoketight and non-combustible.
  • Only fire retardant visquene plastic is acceptable. It is not considered a fire barrier. Permit for visquene is required.

Fire Extinguishers

  • Providing fire extinguishers to be used within the perimeter of the job site as required. Also required for hotwork per each torch assembly. CC Fire Safety will monitor our existing units so it is important to have contractor provided units in place.
to operate fire extinguisher just think of the word pass
To Operate Fire Extinguisher(Just think of the word PASS)

PULL…thesafety pin at the top of theextinguisher, (but let them know…CODE RED!!)

AIM…the nozzle or hose at the base of theflames. Stay between 6-8 ft. away from the flames.

SQUEEZE…orpress the handle (do not turn your back)

SWEEP…withwind in your favor from side to sideat the base of the fire until it goes out.

4 key variables of all fire plans
4 Key Variables of All Fire Plans:
  • How the fire alarm works in the facility.
  • Knowing location of ALL fire exits on the floor where you’re working.
  • Knowing the location of 2 fire extinguishers.
  • Knowing the location of 2 fire alarm boxes
smash the ash
Smash the Ash!
  • Contractors are to ensure that the CC No Smoking policy is followed. Smoking is not permitted on the CC campus or adjacent property.
clean up after yourself
Clean up after yourself!
  • Ensuring that storage, housekeeping, and debris-removal procedures are strictly followed as required.
fire drills
Fire Drills
  • The CC Fire Marshal conducts ILSM fire drills at the Midtown campus, and conducts spot check drills at Off Campus job sites in order to test worker training.
  • Fire drills are required monthly, quarterly, and annually on various shifts.


1. DO NOT move real patients, but rescue dolls.

2. DO NOT USE wet materials

3. PULL fire alarm box

4. DO NOT discharge fire extinguisher

fire plan
Fire Plan
  • In case of fire say “CODE RED SOMEBODY PULL THE ALARM!!”
  • Rescue
  • Close the door
  • Pull alarm
  • Report fire to 42222 or 911
  • Fight fire with extinguisher if possible
  • Seal door with towels, blankets, etc.
  • Close all other doors
  • Await Code Red Team and Fire Dept.
in case of alarm
In Case Of Alarm

1.) Patient Care Facilities, Ascertain Location of Alarm

2.) If Alarm is Adjacent, Floor Above, or Below

-Send one person to area with extinguisher to help and advise that doors are closed.

3.) Non-Patient Care facilities evacuate immediately

non coded fire alarm system
Non-Coded Fire Alarm System

If your area is not listed under the fire alarm coded system, then it is non-coded. Occupied areas included are:

Patient Care: Voice Systems A, C, E, I (Eye), P, R

Patient Care: Interior Coded Systems U

Non-Patient Care: BB, CC, DD, EE, GG, JJ, L, NA-NE, UA, UU, W

fire evacuation levels
Fire Evacuation Levels
  • Single room by first responder.
  • More than one room by first responder
  • Horizontal one smoke zone to another by nurse manager.
  • Building sector (Floor above, below) by HEICS
  • Entire facility evacuation by incident command.

Note: All oxygen zone valve shutdown will be by the

CCF Code-Red Team

Area Of Refuge

C-Clear all ambulatory out of stairs

C-Call incident command and provide information

S-Stage patients on stair landing

W-Wait in stair for emergency responders



01. Exit(s) or Corridor(s) were obstructed? [Exits obstructed]

a. Equipment/tools /debris blocking exit or corridor

b. Inadequate exit signage

c. Job to be shutdown while immediate issue is fixed.

02. Fire alarm and/or Fire Suppression system was impaired (firewatch)? [Inadequate fire watch]

a. Fire watch log not filled out at survey

b. Fire watch not occurring.

c. Fire watch log not faxed in realtime

03. ILSM barrier was not satisfactory or approved? [Inadequate ILSM barrier]

a. Door open to the site.

b. Door does not latch

c. Opening in barrier wall

d. Opening in fire retardant zipwall, except when approved negative air vent

e. Lack of barrier or zipwall where called for

f. No rated fire door barrier when it is required

04. Inadequate fire extinguishers on job site? [Inadequate fire protection]

a. No fire extinguishers on site

b. No fire extinguisher for hot work

c. Fire extinguisher is inaccessible

d. Fire extinguisher has no charge

e. In house fire extinguisher being used in project

f. Fire extinguisher out of date

g. Fire extinguisher have not received monthly visual quick check

05. Violation of CCF Smoking Policy? [Smoking on site]

a. Worker smoking at job site.

b. Worker smoking on campus and adjacent spaces to it.


06. Workers not trained in fire safety or ILSM (job board 8 items/ID)? [ No fire or ILSM training]

a. Worker has no ID badge

b. Worker has no temp paper ID card

c. Worker does not have temp paper ID card filled out

d. Worker using temp paper ID card with an old date indicating they have not attended the

Tuesday Class

e. No job board for the project

f. Job board floor plan incomplete

1. Missing sprinkler shut off valve

2. Missing sprinkler shut off tool

3. Missing all exits

4. Missing fire alarm boxes

5. Missing fire extinguishers

6. Missing barriers if applicable

7. Missing fire alarm display device if applicable

8. Missing fire plan

9. Permit not posted on the job board

10. Worker unaware of job board and cannot relate to inspector

11. Job board not organized for ready emergency use

07. Construction storage, housekeeping and debris removal unsatisfactory? [Poor housekeeping]

a. Debris and material being moved through halls without a hard flip hinged cover

b. Debris found at job site 24 hours after originally found

c. Area in need of clean up

d. Unauthorized storage of construction materials and equipment


08. No permit (open burning, ceiling tile, hazardous substance)? [ fire protection system impaired]

a. No CRRAS permit posted on job board

b. No OBP posted on job board

c. No OBP posted at direct site of hotwork

d. No HSP posted on job board

e. No HSP posted at direct site of where such are used/stored.

f. No NFPA 704 posted at site where Hazardous material is used and stored

g. No labels or cans, boxes, tanks, etc duplicating OBP number

h. No OBP for use/storage non hot work related hazardous materials

i. No FRZP posted where zipwall is hung, all locations

j. No FRZP posted on the job board

k. No CTP posted on job board

l. No CTP posted at all locations where tiles are out.

m. Permits expired or for the wrong location

n. No FSPP posted on job board.

o. No FSPP available where the firestopping work is occurring

p. No temporary firestop where required.

q. No city building or other city permits posted on job board

r. No city fire alarm or sprinkler system installation permits posted on job

board as applicable

09. Unsafe condition [tool unattended, electrical, etc.]?

a. Tool left unattended in open grid ceiling. Confiscated

b. Tool left unattended and plugged in on ground level. Confiscated

c. Unsafe electrical. Remove from site

d. Long materials being moved in the house without a spotter or flag.

e. Unsecured compressed gas tanks

f. Miscellaneous Hazard

10. No items noted (1-9 above)? [None]