Impairment Notice
Building Fire System Impairment

Section 1 – General Information (Completed by requesting organization)
Building Name:

Building Address:

Impairment Coordinator
Bob Slavik 303-273-3312 / 303-885-8557 (Primary);
(Name and phone number):
Ray Castillo 303-273-3263 / 720-496-7782 (Back up);
Craig Crow 303-273-3356 / 303-421-0832 (Back up)
CSM Project Manager

(Name and phone number):
Contractor

(Company name, name of onsite
representative and phone number):
Section 2 – Impairment Information (Completed by requesting organization)
System Impaired:

Location:

Impairment Details/Description:


Hot work is associated with
☐ Yes
If yes provide details on hot work activity:
system Impairment:
☐ No
Start Time and Date:

End Time and Date:

Section 3 – Impairment Requirements and Controls (Completed by impairment coordinator)
☐ Building operating restrictions required
☐ Standard restrictions for Laboratory Buildings
No Open Flame or Flammable Work, this includes:
• No Bunsen burners
• No welding, cutting, or spark producing work such as grinding
• No work with pyrophorics, water reactives or explosives
• No flowing of flammable gases or performing exothermic reactions
• Heat producing experiments must be attended.
☐ Standard restrictions for Non-Laboratory Buildings
No hot work, this includes:
• No open flames,
• No welding, cutting, brazing, soldering
• No spark producing activities such as grinding
☐ Other restrictions required – List:
☐ Notification identifying restrictions posted at entry door

☐ Outage Notification for is to be posed at fire panel/annunciator next to building map
☐ Outage Notification is to be sent to Golden FD, Building Occupants, and State Risk
☐ Notify the Fire System monitoring company prior to impairing the fire protection system
☐ Fire Watch Required – Complete the Fire Watch Form and brief workers to the requirements
☐ Building Evacuation/Closure Required
☐ Additional fire extinguishers are required – Number/Type/Location:
☐ Temporary/standby protection is required – Details:
☐ Spare sprinkler parts are required to be available
☐ Hot work associated with the system impairment is authorized
☐ Post Fire Department Connection (FDC) status – Details:
Section 4 – Impairment Authorization
Signature of Impairment Coordinator: _______________________________________ Date:____________________
Rev. July 2017