Fire and Life Safety (FLS) Frequently Asked Questions

Fire and Life Safety General

1. Who decides what fire alarm and fire sprinkler deferred submittal documents can be reviewed in the field?

The decision to review these documents is based on HCAI staff workload. The field Fire and Life Safety Officer decides what fire alarm and fire sprinkler deferred submittal documents are reviewed in the field. The HCAI FREER Manual is used as a guide for these projects.

2. What are the code requirements for temporary construction barriers?

Please refer to HCAI′s Code Application Notice (CAN) 9-3301 (formerly 9-1401) for the code requirements.

**3. Can a licensed specialty contractor prepare construction documents for a project consisting only of a fire sprinkler system?**

Yes, if the sprinkler piping does not exceed 2.5 inches in diameter. Upon submittal to the Office, the contractor shall include a signed statement stating that he or she is licensed, the number of the license, and that the license is in full force and effect, in accordance with California Administrative Code (CAC) Section 7-115 (c).

4. As used in Code Application Notice CAN 2-703.3, what does the term “manufacturer′s qualified technical personnel” mean?

The “manufacturer′s qualified technical personnel” means someone who is involved in the research, development, design, testing, listing, etc. of the product that is being proposed as a substitute or to be used in an alternative configuration. For example, this individual may be a member of the engineering staff for a firestop company who is involved in product:

Development
In-house testing
Characteristics and behaviors under fire conditions
Performance and suitability for the various testing conditions and circumstances
Performance during full-scale testing at the testing laboratory, what its limitations are, etc.

This person is typically not a sales person but he or she is part of the technical group responsible for R&D. He or she may or may not be a registered professional engineer, but may be more qualified to render an engineering opinion regarding their product than a third party fire protection consultant who is paid to review test data, usually provided by this same individual. Systems that are unusually complex or involve multiple disciplines may require a licensed professional to take responsibility for the proposed substitution or it may require full-scale testing by an approved testing agency. The architect or engineer in responsible charge has complete responsibility for any design alternatives proposed and acceptable to them for their project.

5. Which sheets of the construction documents should contain the details for temporary construction barriers: demolition sheets, architectural sheets, both?

Demolition sheets.

6. Temporary construction barrier partitions are often built in the existing corridors (parallel with the corridor walls). What are HCAI′s recommendations for permissible corridor width for this interim condition?

OSHPD′s recommendations are:

6 feet minimum where serving patients
44 inches elsewhere
See Code Application Notice (CAN) 9-3301 for additional information.

7. Who can submit (stamp) deferred approval fire sprinkler or fire alarm construction documents for projects in health care facilities?

Submittal Type	Activity	Activity Performed By
Fire Sprinkler	Designed, Stamped, and Signed	Mechanical Engineer or Architect
Fire Alarm	Designed, Stamped, and Signed	Electrical Engineer or Architect
Bracing and hangers for sprinkler piping 2-1/2″ or larger	Designed, Stamped, and Signed	Architect or an Engineer (Mechanical, Civil or Structural)

**Fire Protection Engineer is currently not approved for design of construction in healthcare facilities.

CAC Section 7-126 (c) states “Stamping and signing of deferred submittals shall comply with Section 7-115 (a) and (b).”

CAC Section 7-115 (a) and (b) states “All construction documents or reports…shall be prepared under an architect or engineer in responsible charge… A mechanical or electrical engineer may prepare construction documents or reports for projects where the work is predominately of the kind normally prepared by mechanical or electrical engineers. A civil engineer may prepare construction documents or reports for the anchorage and bracing of nonstructural equipment.”

CAC Section 7-115 (c) allows a licensed specialty contractor to prepare construction documents and administer the work of construction for health facility construction projects of a limited scope. This includes stand-alone sprinkler system projects where none of the piping exceeds 2 ½” as well as stand-alone power-limited fire alarm projects (replacement, upgrades, etc.) but does not allow a contractor to design (stamp) fire sprinkler or fire alarm work that is a part of a project prepared by an architect or engineer.

8. For a remodel of a limited area of a healthcare facility, how should hazardous materials inventories be categorized?

List of hazardous materials by room?
Total of quantities by room?
Total of quantities by floor?
Include areas not in the area of remodel?

To expedite the plan review process and evaluate compliance with the requirements for the storage and use of hazardous materials, a Hazardous Materials Inventory Statement prepared in accordance with HCAI Policy Intent Notice (PIN) 8, must be included on or with construction documents submitted to HCAI.

For projects that involve an inordinate amount of hazardous materials, a clear identification of the boundaries of the hazardous materials control areas may be necessary, and a complete inventory of the entire control area may be warranted to determine if the change of quantities in the new room/area will impact the occupancy classification. It is recommended the project be reviewed early with the HCAI field Fire and Life Safety Officer to ensure all aspects of this complex issue are being adequately addressed.

Move to Top

Fire and Life Safety Smoke Barriers

1. Are smoke compartment walls required to be provided in ground level lobbies?

Smoke barriers for occupancies in Groups I-2 and I-2.1 shall be provided to subdivide every story used by patients for sleeping or treatment and to divide other stories with an occupant load of 50 or more persons, into at least two smoke compartments.

The 2016, 2019, and 2022 California Building Code, Section 407.5, Exception 3 includes conditions that may permit the omission of smoke compartments in a story or portion of a story when the area is not classified as a Group I-2 or I.2.1.

2007 California Building Code (CBC) Section 407.4
2010 California Building Code (CBC) Section 407.4
2013 California Building Code (CBC) Section 407.5
2016 California Building Code (CBC) Section 407.5
2019 California Building Code (CBC) Section 407.5
2022 California Building Code (CBC) Section 407.5

2. Smoke zones are required to be 150 feet maximum in length or width but HCAI is interpreting that to mean both length and width. As long as compartment size is less than 22,500 square feet, does the length or width need to be limited?

For projects governed by the 2001 CBC, the area within a smoke-control zone shall not exceed 22,500 square feet and its width or length shall not exceed 150 feet. However, for projects governed by the 2007, 2010, 2013, 2016, 2019 and 2022 CBC, a smoke compartment shall have an area of not more than 22,500 square feet and the travel distance from any point in a smoke compartment to a smoke barrier door shall not exceed 200 feet. There are no length or width restrictions in the 2007, 2010, 2013, 2016, 2019 or 2022 CBC.

2001 California Building Code (CBC) Section 308.2.2.1
2007 California Building Code (CBC) Section 407.4
2010 California Building Code (CBC) Section 407.4
2013 California Building Code (CBC) Section 407.5
2016 California Building Code (CBC) Section 407.5
2019 California Building Code (CBC) Section 407.5.1 and 407.5.2
2022 California Building Code (CBC) Section 407.5.1 and 407.5.2

3. Is each door in a smoke barrier partition, other than cross-corridor doors, required to be provided with an electric hold-open device in addition to the “self-closing” door closer (such as a janitor closet door or bathroom door)?

No. The CBC general provisions for closing fire doors specify that fire doors can be either self-closing or automatic-closing. The CBC further clarifies that when doors are automatic-closing, they must be automatic-closing by actuation of a smoke detector (not a fusible link or heat detector). The CBC requires only those smoke barrier doors that are installed across corridors to be automatic-closing by smoke detection.

2007 California Building Code (CBC) Sections 709.5, 715.4.7 and 715.4.7.3
2010 California Building Code (CBC) Sections 710.5, 715.4.8 and 715.4.8.3
2013 California Building Code (CBC) Sections 709.5 Exception 1, 716.5.9 and 716.5.9.3
2016 California Building Code (CBC) Sections 709.5.1, 716.5.9 and 716.5.9.3
2019 California Building Code (CBC) Sections 709.5.1, 716.2.6.1 and 716.2.6.6
2022 California Building Code (CBC) Sections 709.5.1, 716.2.6.1 and 716.2.6.6

Yes. For projects governed by the 2001 CBC; the CBC states “Doors installed across corridors shall comply with Section 713.6.1, Item 3, and doors on the floor or in the affected zone shall automatically close if the fire alarm or sprinkler system is activated.”

2001 California Building Code (CBC) Section 308.2.2.1 Item 5

4. In Group I-2, I-2.1 and ambulatory care facilities, where doors are installed across a corridor, are a pair of opposite swinging doors required?

Yes. The CBC 2016, Sections 709.5 and 909.5 unintentionally create ambiguity regarding the requirement for opposite swinging doors where doors are installed across a corridor at a smoke barrier opening.

CBC 2016 Section 709.5, Exception 1 includes language that infers that opposite swinging doors will be present when swinging doors are installed across corridors. The actual requirement is omitted.

It is, however; still the intent to require that such doors be opposite swinging. NFPA 101–2012, Section 18.3.7.6 (3) requires pairs of swinging doors installed across corridors in smoke barrier openings be arranged so that each door swings in a direction opposite from the other.

2019 and 2022 CBC Sections 709.5.1 and 909.5.3.1 are amended to clearly require in Group I-2, where swinging doors are installed across a corridor, such doors shall be opposite swinging pairs.

Any installation of swinging doors across corridors at smoke barrier openings other than pairs of opposite swinging doors is not acceptable.

2010 California Building Code (CBC) Sections 709.5, Exception 1 and 909.5.2, Exception 3
2013 California Building Code (CBC) Sections 709.5, Exception 1 and 909.5.2, Exception 3
2016 California Building Code (CBC) Sections 709.5, Exception 1 and 909.5.3, Exception 3
2019 California Building Code (CBC) Sections 709.5.1 and 909.5.3.1
2022 California Building Code (CBC) Sections 709.5.1 and 909.5.3.1

Move to Top

Fire and Life Safety Fire Resistant Materials and Construction

1. In buildings of Type I or II construction, is a fire block required at the corridor ceiling?

No. Fire blocking is only required in combustible construction in accordance with California Building Code (CBC).

2007 California Building Code (CBC) Section 717
2010 California Building Code (CBC) Section 717
2013 California Building Code (CBC) Section 718
2016 California Building Code (CBC) Section 718
2019 California Building Code (CBC) Section 718
2022 California Building Code (CBC) Section 718

2. When is a T-Rating required for penetrations?

The CBC requires through penetrations of fire-resistance rated floors, floor/ceiling assemblies or the ceiling membrane of a roof/ceiling assembly to be protected by a through-penetration firestop system having a F-rating and a T-rating of not less than 1 hour, but not less than the required rating of the floor penetrated. Floor penetrations contained and located within the cavity of a wall (above the floor or below the floor) do not require a T-rating.

The 2013, 2016, 2019 and 2022 CBC permit floor penetrations by floor drains, tub drains or shower drains contained and located within the concealed space of a horizontal assembly without a T rating. Acceptance of such configurations shall be on a case-by-case basis for projects constructed in accordance with the 2007 CBC or 2010 CBC.

The 2016, 2019 and 2022 CBC do not require a T rating for floor penetrations of maximum 4-inch nominal diameter penetrating directly into metal-enclosed electrical power switchgear. Acceptance of such configurations shall be on a case-by-case basis for projects constructed in accordance with the 2007 CBC, 2010 CBC or 2013 CBC.

There are few limited exceptions to this requirement in the CBC. These include penetrating items with a maximum 6-inch nominal diameter penetrating a single fire-resistance-rated floor assembly, provided the aggregate area of the openings through the assembly does not exceed 144 square inches in any 100 square feet of floor area. Refer to the CBC for additional exceptions.

2007 California Building Code (CBC) Sections 712.4.1.1 and 712.4.1.1.2
2010 California Building Code (CBC) Sections 713.4.1.1 and 713.4.1.1.2
2013 California Building Code (CBC) Sections 714.4.1.1 and 714.4.1.1.2
2016 California Building Code (CBC) Sections 714.4.1.1 and 714.4.1.2
2019 California Building Code (CBC) Sections 714.5.1.1 and 714.5.1.2
2022 California Building Code (CBC) Sections 714.5.1.1 and 714.5.1.2

3. Is the dimension for the edge-of-slab to the face of the exterior “curtain wall” required to comply with UL exterior wall perimeter fire containment systems?

Yes. The CBC states “Construction documents for all buildings shall describe the exterior wall envelope in sufficient detail to determine compliance with this code.” These dimensions need to be clearly detailed on the plans, but not necessarily on the construction documents.

2007 California Building Code (CBC) Appendix Chapter 1 Section 106.1.3
2010 California Building Code (CBC) Section 107.2.4
2013 California Building Code (CBC) Section 107.2.4
2016 California Building Code (CBC) Section 107.2.4
2019 California Building Code (CBC) Section 107.2.4
2022 California Building Code (CBC) Section 107.2.4

4. Are there listed fire assemblies for tube steel beams?

At this time there are no tested/approved fire-resistive assemblies for tubular steel members used in the beam configuration. The CBC includes alternative methods for determining fire resistance that can be used to establish fire-resistance. The procedures listed include:

a. Fire-resistance designs documented in approved sources.
b. Prescriptive designs of fire-resistance-rated building elements as prescribed in the Tables in CBC Chapter 7.
c. Calculations in accordance with the CBC Section Calculated Fire Resistance.
d. Engineering analysis based on a comparison of building element, component or assemblies designs having fire-resistance ratings as determined by the test procedures set forth in ASTM E-119 or UL 263.
e. Alternative protection methods as allowed by the CBC.
f. Fire-resistance designs certified by an approved agency.

2007 California Building Code (CBC) Sections 703.3, 720, 721 and 104.11
2010 California Building Code (CBC) Sections 703.3, 720, 721 and 104.11
2013 California Building Code (CBC) Sections 703.3, 721, 722 and 104.11
2016 California Building Code (CBC) Sections 703.3, 721, 722 and 104.11
2019 California Building Code (CBC) Sections 703.3, 721, 722 and 104.11
2022 California Building Code (CBC) Sections 703.2.1, 703.2.2, 703.2.3, 721, 722 and 104.11

5. For interior walls of one-hour fire resistive construction where opening protection is not required, is it permissible for the wallboard to terminate just above the ceiling?

Yes. While interior nonbearing partitions and walls may be required to have a 1-hour fire-resistance rating, there is no requirement that such non-bearing walls and partitions extend above the ceiling.

2007 California Building Code (CBC)
2010 California Building Code (CBC)
2013 California Building Code (CBC)
2016 California Building Code (CBC)
2019 California Building Code (CBC)
2022 California Building Code (CBC)

6. When must upholstered furniture comply with the regulations of the Bureau of Electronic and Appliance Repair, Home Furnishings and Thermal Insulation?

The Bureau of Electronic and Appliance Repair, Home Furnishings and Thermal Insulation is now identified as the Bureau of Household Goods and Services.

All upholstered furniture sold in the State of California must comply with Technical Bulletin 117-2013. Technical Bulletin 117-2013, is therefore by default; the basic standard for upholstered furniture in the State of California.

Since furniture that does NOT comply with the Technical Bulletin 117-2013 standard cannot be sold in the State of California, the only upholstered furniture that would not meet the standard would be personal or homemade furniture brought to a facility by a patient’s family member. Such furniture is exempt from the regulations of the Bureau of Household Goods and Services (formerly the Bureau of Electronic and Appliance Repair, Home Furnishings and Thermal Insulation).

Technical Bulletin 133 was repealed effective January 1, 2015. Technical Bulletin 133 was a flammability standard for seating furniture in public buildings or public assembly areas. Technical Bulletin 133 was, however; applicable only to new furniture used in non-sprinklered facilities including, prisons and jails, hospitals, healthcare facilities, board and care homes, convalescent homes, licensed child care facilities, stadiums, auditoriums, and public assembly areas of hotels and motels. Compliance with Technical Bulletin 133 was voluntary or discretionary in any facility which was fully sprinklered in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

The flammability of mattresses is also a concern and is regulated separately from upholstered furniture. All mattresses sold in the United States must comply with 16 CFR 1633. Mattresses used in public buildings in California, such as hotels and motels, must also comply with Technical Bulletin 129. Mattresses used in high risk occupancies in California, including jails, prisons, penal institutions, correctional facilities, juvenile detention centers, nursing homes, and health care facilities, must comply with Technical Bulletin 121.

Regardless of the above, enforcement of these regulations is not a building regulation. When inquiries regarding these regulations or violations of these regulations come to the attention of HCAI OSHPD staff, the client and their representatives should be advised of the requirements. Enforcement of these regulations is, however; the responsibility of the Local Fire Authority or the Office of the State Fire Marshal.

Sections 19034 and 19161, Business and Professions Code

7. Are through-penetration firestop and membrane penetration details required on construction documents?

The 2001 California Building Code, based on the 1997 Uniform Building Code, required that plans and specifications indicate how required structural and fire-resistive integrity will be maintained where penetrations will be made for electrical, mechanical, plumbing and communication conduits, pipes and similar systems.

The California Building Code, based on the International Building Code, does not require that details for through-penetration firestop systems and membrane penetrations be provided on construction documents. Including such information on construction documents has proven to be problematic and of limited value. Seldom are the firestop systems identified on the construction documents actually utilized on a project. Invariably, the firestop systems used on a project are determined during construction.

Regarding the detailing of firestop systems on construction documents, such detailing is not required. Where such details are provided, they should be considered as typical examples and the following information or similar language shall be considered acceptable:

Where provided, through-penetration firestop system and membrane penetration details are for reference only. Through-penetrations and membrane penetrations shall be protected by an approved penetration firestop system or membrane penetration firestop system installed as tested in accordance with ASTM E 814 or UL 1479, with a minimum positive pressure differential of 0.01 inch (2.49 Pa) of water or as otherwise permitted by CBC, Section 714. Listed through-penetration firestop systems and membrane penetrations shall be installed in accordance with the installation details for listed systems. Listed through-penetration firestop systems, membrane penetration protection and other permitted means and methods of penetration protection shall be submitted for HCAI OSHPD review and approval prior to installation.

2007 California Building Code (CBC), Appendix Chapter 1, Section 106.1.1
2010 California Building Code (CBC), Section 107.2.1
2013 California Building Code (CBC), Section 107.2.1
2016 California Building Code (CBC), Section 107.2.1
2019 California Building Code (CBC), Section 107.2.1
2022 California Building Code (CBC), Section 107.2.1

8. Does a storage room with a floor area greater than 100 sq. ft. require separation and protection?

Yes. An error in the July 1, 2015 Supplement to the 2013 California Building Code created a conflict when storage rooms over 100 sq. ft. were omitted from Table 509 Incidental Uses. Separation and protection of storage rooms over 100 sq. ft. shall be provided. This error is corrected in subsequent editions of the California Building Code.

The separation and protection of such storage rooms is also a requirement of NFPA 101, Section 18.3.2.1.

2007 California Building Code (CBC) Section 508.2 and Table 508.2
2010 California Building Code (CBC) Section 508.2.5 and Table 508.2.5
2013 California Building Code (CBC) Section 509 and Table 509
2016 California Building Code (CBC) Section 509 and Table 509
2019 California Building Code (CBC) Section 509 and Table 509
2022 California Building Code (CBC) Section 509 and Table 509.1
2000 NFPA 101, Section 18.3.2.1 and Table 18.3.2.1
2012 NFPA 101, Section 18.3.2.1 and Table 18.3.2.1

9. Do openings located in Type V-A eave projections require protection?

No. In accordance with the California Building Code, eave projections from walls of Type V construction shall be of any approved material.

The CBC, further clarifies that combustible projections extending to within 5 feet of the line used to determine the fire separation distance, or located where openings are not permitted, or where protection of some openings is required shall be of at least 1-hour fire-resistance-rated construction, heavy timber construction, fire-retardant-treated wood or as required by the 2007 thru 2016 CBC Section 1406.3 or 2019/2022 CBC Section 705.2.3.1.

2007 thru 2016 CBC, Section 1406.3, Exception 3 or 2019/2022 CBC Section 705.2.3.1, Exception 3 specify that balconies and similar projections on buildings of Type III, IV and V construction shall be permitted to be of Type V construction, and shall not be required to have a fire-resistance rating where sprinkler protection is extended to these areas. In Type V-A building construction, balconies shall be constructed as continuations of fire-resistance rated floor assemblies. While eave projections may not necessarily be considered as similar to balcony projections, they are continuations of roof-ceiling assemblies. As such, the presence of fire sprinkler protection in the combustible attic space would preclude the need for fire-resistance rated construction and opening protection in eave projections.

CBC, Chapter 12 contains very specific and comprehensive requirements for attic ventilation. Prohibiting the location of vents in eave projections can create conflicts with the ventilation requirements for attic spaces.

Therefore, where proximity to a property line is not a concern, eave projections need not be one-hour fire-resistive construction and openings shall not be prohibited or require protection.

2007 California Building Code (CBC) Sections 704.2, 704.2.2 and 1406.3
2010 California Building Code (CBC) Sections 705.2, 705.2.2 and 1406.3
2013 California Building Code (CBC) Sections 705.2, 705.2.2 and 1406.3
2016 California Building Code (CBC) Sections 705.2, 705.2.2 and 1406.3
2019 California Building Code (CBC) Sections 705.2, 705.2.2 and 705.2.3
2022 California Building Code (CBC) Sections 705.2, 705.2.2, 705.2.3 and 705.2.3.1

10. When do bracing members require fire resistive protection in accordance with the requirements for the primary structural frame?

Any structural item that provides a direct connection to a column or a bracing member that is designed to carry a gravity load is considered to be part of the primary structural frame. The intent is to delay vertical (gravity) load-carrying collapse of a building due to fire exposure for a theoretical duration of time.

The CBC Section 202, definition of Primary Structural Frame, Item 4, states that bracing members that are essential to the vertical stability of the primary structural frame under gravity loading.This definition serves to further clarify information previously located in the 2007 CBC, Table 601, Footnote a.

Typically, for floor and roof construction, most braces connected to the structural frame provide lateral support against earthquake or wind forces. As such, these braces are considered to be secondary members. Such brace construction is required to be shown on the Structural Design Drawings in accordance with 2016 AISC 341-16 Seismic Provisions for Structural Steel Buildings, Section A4.1, Items (a) and (b). Classifying such braces as secondary members appears to be an unintended consequence of revisions to the 2009 IBC concerned with the, September 11, 2001, collapse of the World Trade Center. Nevertheless, it is currently the requirement.

On rare occasion, bracing members essential to the support of vertical (gravity) load carrying members (columns) of the primary structural frame may be provided. While these bracing members do not carry a gravity load, they would, nevertheless, be considered as an element of the primary structural frame. An example of such bracing would be knee braces stiffening a column. Since the floor-to-floor height of hospital construction is generally limited to no more than a maximum of 20 feet, such elements would seldom be utilized in hospital design.

For additional understanding, an example of knee braces functioning as primary members is provided in the accompanying detail. Details of eccentric and concentric braces provided for lateral support and therefore considered secondary members are also included.

2007 California Building Code (CBC), Section 602.1 and Table 601
2010 California Building Code (CBC), Section 202, Section 602.1 and Table 601
2013 California Building Code (CBC), Section 202, Section 602.1 and Table 601
2016 California Building Code (CBC), Section 202, Section 602.1 and Table 601
2019 California Building Code (CBC), Section 202, Section 602.1 and Table 601
2022 California Building Code (CBC), Section 202, Section 602.1 and Table 601

Diagrams:

11. What training for special inspection agencies and special inspectors is acceptable for special inspections of fire-resistance penetrations and joints?

In accordance with California Building Code Section 202, a special inspector is a qualified person employed or retained by an approved agency and approved by the building official as having the competence necessary to inspect a particular type of construction requiring special inspection.

To inspect fire-resistant penetrations and joints, training is required to qualify a special inspector and the special inspection agency.

Table 1 of AC291 indicates the ICC Credential of Learning Achievement (CLA), UL Firestop Examination, FM Firestop Examination, or IFC third-party Firestop Special Inspector Examination are acceptable training programs for a special inspector. To qualify special inspectors for the inspection of fire-resistant penetrations and joints, the ICC CLA, UL, FM or IFC Firestop Examinations are acceptable to OSHPD.

Historically, the UL and the FM training was for contractors for the proper selection and installation of a system. The training for contractors is not adequate training for special inspectors for fire-resistant penetrations and joints. If this level of training is received, an additional ICC CLA training, UL, FM or IFC Firestop Examinations is required for special inspectors to perform the inspection of fire-resistant penetrations and joints.

2013 California Building Code (CBC) Sections 1705.16.1, 1705.16.2, 1705A.16.1 & 1705A.16.2
2016 California Building Code (CBC) Sections 1705.17.1, 1705.17.2, 1705A.17.1 & 1705A.17.2
2019 California Building Code (CBC) Sections 1705.17.1, 1705.17.2, 1705A.17.1 & 1705A.17.2
2022 California Building Code (CBC) Sections 1705.18.1, 1705.18.2, 1705A.18.1 & 1705A.18.2

Move to Top

Fire Alarm

1. Are conduits and boxes allowed to be installed prior to HCAI′s approval of a fire alarm deferred submittal?

No, unless shown on the approved Electrical plans. If the conduits and boxes are not shown on the approved Electrical plans, the California Administrative Code requires that submittal documents must be approved by HCAI prior to the installation of deferred submittal items.

2007 California Administrative Code (CAC) Section 7-126(d)
2010 California Administrative Code (CAC) Section 7-126(d)
2013 California Administrative Code (CAC) Section 7-126(d)
2016 California Administrative Code (CAC) Section 7-126(d)
2019 California Administrative Code (CAC) Section 7-126(d)
2022 California Administrative Code (CAC) Section 7-126(d)

2. Where should the pull station be located in relationship to an exit?

The California Fire Code (CFC) states that manual fire alarm boxes must be located not more than 5 feet from the entrance to each exit. NFPA 72 further clarifies that manual fire alarm boxes shall be located within 5 feet (60 inches) of the exit doorway opening at each exit on each floor.

2007 California Fire Code (CFC) Section 907.4.2 and NFPA 72-2002 Section 5.12.6
2010 California Fire Code (CFC) Section 907.4.1 and NFPA 72-2010 Section 17.14.6
2013 California Fire Code (CFC) Section 907.4.2.1 and NFPA 72-2013 Section 17.14.8.4
2016 California Fire Code (CFC) Section 907.4.2.1 and NFPA 72-2016 Section 17.14.8.4
2019 California Fire Code (CFC) Section 907.4.2.1 and NFPA 72-2016 Section 17.14.8.4
2022 California Fire Code (CFC) Section 907.4.2.1 and NFPA 72-2022 Section 17.15.9.4

3. Does HCAI accept the use of driven pins for the support of fire alarm conduits?

Yes. Power-Actuated Fasteners are permitted to be used for support of gravity loads not to exceed 50% of the rated capacity of the fastener (approximately 100 pounds maximum). Power-Actuated Fasteners are also permitted to resist seismic horizontal forces in shear but are not permitted for seismic tensile loads.

2007 California Building Code (CBC) and Code Application Notice (CAN) 2-1916A.8
2010 California Building Code (CBC) Section 1916A.7
2013 California Building Code (CBC) Section 1913A.7
2016 California Building Code (CBC) Sections 1901.3.4 and 1910A.5
2019 California Building Code (CBC) Sections 1909.2.7 and 1905A.5
2022 California Building Code (CBC) Sections 1909.2.7 and 1910A.5

4. In Group I Occupancies, are fire alarm notification devices required to be designed and installed in accordance with the NFPA 72 provisions for Public Mode or for Private Mode?

NFPA 72 defines:

Private Operating Mode as “audible or visible signaling only to those persons directly concerned with the implementation and direction of emergency action initiation and procedure in the area protected by the fire alarm system” (or “staff-alerting”).
Public Operating Mode as “audible or visible signaling to occupants or inhabitants of the area protected by the fire alarm system” (or “occupant alerting”).

Most healthcare facilities have areas within the building that are considered:

“Private Mode” (i.e. patient sleeping areas, critical care areas, operating rooms, etc.) where alerting of the facility staff is necessary to affect the relocation of patients who are incapable of unassisted self-preservation.
“Public Mode” (i.e. lobbies, waiting areas, dining facilities, etc.) where occupants are capable of unassisted self-preservation.
Mixed (i.e. patient rooms during visitation, labor/delivery rooms with family visiting, outpatient facilities used for in-patient diagnostic & treatment, etc.).

The only distinction between areas requiring public mode notification and areas requiring private mode notification is the minimum sound pressure levels of the audible notification appliances. To ensure that audible signals are clearly heard:

Public Mode – NFPA 72 requires audible notification appliances (i.e. horns, bells, chimes, etc.) have a sound level at least 15 dBabove the average ambient sound level of or 5 dB above the maximum sound level, whichever is greater, measured 5 feet above the floor in the occupiable area.
Private Mode – NFPA 72 requires audible notification appliances (i.e. horns, bells, chimes, etc.) have a sound level at least 10 dBabove the average ambient sound level of or 5 dB above the maximum sound level, whichever is greater, measured 5 feet above the floor in the occupiable area.

The California Fire Code (CFC) requires audible appliances be used in non-patient areas; however, visible appliances may be used in lieu of audible appliances in patient occupied areas – clearly a ‘private mode’ consideration. When the designer elects to use this provision of the code, strobes must be located in every room to notify staff of the event of a fire. The California Fire Code (CFC) requires that audible appliances placed in patient areas be only chimes or similar sounding appliances for alerting staff – also a ‘private mode’ requirement. To avoid confusion during an emergency, mixing of the alarm sounds (i.e. chimes and horns) within the same building is prohibited by the California Fire Code (CFC). Therefore, audible notification devices in healthcare facilities must be staff alerting chimes or similar sounding appliances throughout the building, including those portions of the building that are clearly public mode notification areas. However, the designer need only meet the ‘private mode’ audible sound pressure level requirements of 10 dB above ambient throughout the facility.

The California Fire Code (CFC) contains the requirements for visual notification appliances in all public and common use areas. These requirements override the provisions in NFPA 72 for Public or Private Mode visual notification appliances and required visible alarm notification appliances in public use areas and common use areas included but not limited to:

Band rooms
Classrooms
Corridors
Gymnasiums
Lobbies
Meeting and conference rooms
Multipurpose rooms
Music practice rooms
Occupational shops
Occupied rooms where ambient noise impairs hearing of the fire alarm
Sanitary facilities including restrooms, bathrooms and shower rooms
Shared office rooms used by two or more persons
Normally occupied room(s) used by two or more persons, such as mother’s room, phone room, quiet room, wellness room, etc.
Normally occupied storage room/area
Exam rooms in medical office buildings

Exception: Where employee work areas have audible alarm coverage, the notification appliance circuits serving the employee work areas shall be initially designed with not less than 20-percent spare capacity to account for the potential of adding visible notification appliances in the future to accommodate hearing-impaired employee(s).

(Common Use Area is a term defined in CBC 2 and originally intended for accessibility and adopted for HCD 1-AC. Common Use is an adopted term and is applicable to this section. SFM created this list as a sampling of areas considered common use.)

2007 California Fire Code (CFC) Sections 907.2.6.2, 907.10.1.1 and 907.10.2; NFPA 72-2002 Sections 3.3.122, 7.4.2.1, 7.4.3.2, 7.5 and 7.6 and Code Application Notice (CAN) 9-907.10.1.1
2010 California Fire Code (CFC) Sections 907.6.2.1, 907.6.2.5 and 907.10.1.1; NFPA 72-2010 Sections 3.3.169, 18.4.3.1, 18.4.4.1, 18.5 and 18.6 and Code Application Notice (CAN) 9-907.6.2.3.1
2013 California Fire Code (CFC) Sections 907.5.2.1, 907.5.2.3.1 and 907.5.2.5; NFPA 72-2013 Sections 3.3.185, 18.4.3.1, 18.4.4.1, 18.5 and 18.6 and Code Application Notice (CAN) 9-907.5.2.3.1
2016 California Fire Code (CFC) Sections 907.5.2.1, 907.5.2.3.1 and 907.5.2.5; NFPA 72-2016 Sections 3.3.183, 18.4.3.1, 18.4.4.1, 18.5 and 18.6
2019 California Fire Code (CFC) Sections 907.5.2.1, 907.5.2.3.1 and 907.5.2.5; NFPA 72-2016 Sections 3.3.183, 18.4.3.1, 18.4.4.1, 18.5 and 18.6.
2022 California Fire Code (CFC) Sections 907.5.2.1, 907.5.2.3.1 and 907.5.2.5; NFPA 72-2022 Sections 3.3.201.1, 3.3.201.2, 18.4.3.1, 18.4.4.1, 18.5 and 18.6.

5. Are fire alarm notification devices required in operating rooms?

Yes. The California Fire Code (CFC) requires that audible alarm notification appliances shall provide a sound pressure level of 15 decibels (dBA) above the average ambient sound level or 5 dBA above the maximum sound level having a duration of at least 60 seconds, whichever is greater, in every occupied space within the building.

In lieu of compliance with the audible alarm notification appliance sound pressure level requirements of the CFC within the operating room, fire alarm notification devices located in operating rooms are permitted to instead be visible devices, in accordance with an exception to the CFC audible alarm requirements. Often, the omission of audible devices and the installation of visible devices is the preferred means of notification in operating rooms.

When a procedure is underway in an operating room, it is not always possible for a surgeon to immediately respond to a fire alarm located elsewhere within the building; often the procedure must continue without interruption or at best, be brought to a point where the procedure can be safely delayed without placing the patient in undue peril. Since the potential for distracting the surgeon is high when the fire alarm activates, possibly resulting in harmful outcomes, locating the audible notification appliance within the operating room is not recommended. Typically, the omission of audible devices and the installation of visible devices is the preferred means of notification in operating rooms.

If the visible device is not the preferred means of notification, then the audible device must be located in the vicinity of the operating room, such that the required sound pressure level is met within the operating room. The ambient sound level of each operating room (music, saws, tools, closed doors, etc.) must be considered and audible notification devices provided such that ambient noise does not impair hearing of the fire alarm, and compliance with required sound pressure level requirements are met throughout.

2007 California Fire Code (CFC) Section 907.10.2
2010 California Fire Code (CFC) Sections 907.6.2.1 and 907.6.2.1.1
2013 California Fire Code (CFC) Sections 907.5.2.1 and 907.5.2.1.1
2016 California Fire Code (CFC) Sections 907.5.2.1 and 907.5.2.1.1
2019 California Fire Code (CFC) Sections 907.5.2.1 and 907.5.2.1.1
2019 California Fire Code (CFC) Sections 907.5.2.1 and 907.5.2.1.1
2022 California Fire Code (CFC) Sections 907.5.2.1 and 907.5.2.1.1

Yes. The California Fire Code (CFC) enumerates general areas where visible fire alarm notification appliances shall be provided. When fire-protection signaling systems are provided in health care facilities, such systems shall include visible notification devices in the following areas.

Restrooms (Toilet Rooms) and Similar Uses Including the Following:

Public restrooms
Staff restrooms
Locker rooms
Dressing rooms
Accessible patient restrooms
Patient restrooms that do not serve individual patient rooms

Corridor System and Similar Uses Including the Following:

Public corridors
Staff corridors
Service corridors
Vestibules
Passageways

Gymnasiums and Similar Uses Including the Following:

Physical therapy
Rehabilitation therapy
Occupational therapy

Multipurpose Rooms and Similar Uses Including the following:

Auditoriums
Dining rooms
Cafeterias
Occupiable outdoor patios and courts that require exiting through the building

Occupied Rooms Where Ambient Noise Impairs Hearing of the Fire Alarm Including the Following and Similar Uses:

Kitchens
Laundry areas
Central sterilization
Mechanical equipment rooms
Generator rooms
Boiler rooms
Power plants

Lobbies and Similar Uses Including the Following:

Elevator lobbies

Meeting Rooms and Similar Uses Including the Following (please also see Fire Alarm FAQ #4 regarding Public and Private mode requirements)

Conference rooms
Waiting rooms
Reception rooms/areas
Lounges Chapels

Any Other Area for Common Use with an Occupant Load of at Least Two (2) Including the following and Similar Uses (please also see Fire Alarm FAQ #4 regarding Public and Private mode requirements):

Pharmacies
Laboratories
Office rooms/areas
Imaging control rooms Operating rooms

Rooms Used for Sleeping and Similar Uses, (NOT TO INCLUDE PATIENT ROOMS):

Sleeping rooms and suites for persons with hearing impairments shall have a visual fire alarm connected to the building fire-protective signaling system and NFPA 72. Application of this requirement shall be by sleeping room/suite type (for example: doctors sleeping, family sleeping, etc.).

When visible notification devices are used in patient occupied areas in lieu of audible devices, visible notification appliances shall be located in all rooms and areas.

2007 California Fire Code (CFC), Sections 907.10.1.1 and 907.2.6.2
2007 California Building Code (CBC), 1114B.2.2
NFPA 72 2007 National Fire Alarm Code, Section 7.5.4.6
2010 California Fire Code (CFC), Sections 907.6.2.3.1 and 907.6.2.5
2010 California Building Code (CBC), Section 1114B.2.2
NFPA 72 2010 National Fire Alarm & Signaling Code, Section 18.5.4
2013 California Fire Code (CFC), Sections 907.5.2.3.1 and 907.5.2.5
2013 California Building Code (CBC), Section 11B-702.1
NFPA 72 2013 National Fire Alarm & Signaling Code, Section 18.5.5
2016 California Fire Code (CFC), Sections 907.5.2.3.1 and 907.5.2.5
2016 California Building Code (CBC), Section 11B-702.1
NFPA 72 2016 National Fire Alarm & Signaling Code, Section 18.5.5
2019 California Fire Code (CFC), Sections 907.5.2.3.1 and 907.5.2.5
2019 California Building Code (CBC), Section 11B-702.1
NFPA 72 2016 National Fire Alarm & Signaling Code, Section 18.5.5
2022 California Fire Code (CFC), Sections 907.5.2.3.1 and 907.5.2.5
2022 California Building Code (CBC), Section 11B-702.1
NFPA 72 2022 National Fire Alarm & Signaling Code, Section 18.5.5

Move to Top

Fire/Smoke Dampers (FSD)

1. Can a horizontal FSD be used at the top of a shaft or does a rated enclosure “dog house” need to be constructed so the installation of a vertical FSD can be used?

If the damper is listed for the application, as required by the California Building Code, additional framing or a “dog house” is not required.

2007 California Building Code (CBC) Section 716.5.3
2010 California Building Code (CBC) Section 716.5.3
2013 California Building Code (CBC) Section 717.5.3
2016 California Building Code (CBC) Section 717.5.3
2019 California Building Code (CBC) Section 717.5.3
2022 California Building Code (CBC) Section 717.5.3

2. Does each smoke fire damper require individual service power disconnecting means?

Yes. However, the California Electrical Code (CEC) regulates the types of disconnecting means that may be used; For permanently connected appliances rated at not over 300 volt-amperes or 1/8 hp., the branch-circuit overcurrent device shall be permitted to serve as the disconnecting means. 2019 CEC requires that the switch or circuit breaker is within sight from the appliance or is lockable in accordance with 110.25.

2007 California Electrical Code (CEC) Section 422.31
2010 California Electrical Code (CEC) Section 422.31
2013 California Electrical Code (CEC) Section 422.31
2016 California Electrical Code (CEC) Section 422.31
2019 California Electrical Code (CEC) Section 422.31
2022 California Electrical Code (CEC) Section 422.31

Move to Top

Fire Sprinkler Protection

1. How current must water supply capacity information that is provided with a fire sprinkler system design submittal be?

A 2019 CBC and a 2022 CFC amendment to NFPA 13 Standard for the Installation of Sprinkler Systems specify that such test shall not be older than 6 months; therefore, where a water flow test is used as the basis of a sprinkler system design, the test shall be no more than 6 months prior to the plan submittal unless otherwise approved by the authority having jurisdiction. The 2007, 2010, 2013 and 2016 CBC permitted a test no older than 1 year. Where drought or other concerns are present, an analysis provided by the water utility is also acceptable.

2007 California Building Code (CBC) Chapter 35 and NFPA 13-2002 Subsection 14.2.1
2010 California Building Code (CBC) Chapter 35 and NFPA 13-2010 Subsection 22.2.1.1
2013 California Building Code (CBC) Chapter 35 and NFPA 13-2013 Subsection 23.2.1.1
2016 California Building Code (CBC) Chapter 35 and NFPA 13-2016 Subsection 23.2.1.1
2019 California Building Code (CBC) Chapter 35 and NFPA 13-2016 Subsection 23.2.1.1
2022 California Fire Code (CFC) Chapter 80 and NFPA 13-2022 Subsection 23.1.3(18)(e)

2. When is a fire sprinkler system floor control valve required?

California Fire Code (CFC) requires floor control valves on each floor of high-rise buildings and Group I-2 occupancies having occupied floors located more than 75 feet above the lowest level of fire department access. The 2010, 2013, 2016, 2019 and 2022 California Fire Code (CFC) also require control valves in buildings where the floor level of the highest story is located more than 30 feet above the lowest level of fire department vehicle access, when a building is four or more stories in height or when a building is two or more stories below the highest level of fire department vehicle access. NFPA 13 limits the size of light hazard and ordinary hazard fire sprinkler systems to no more than 52,000 square feet. A control valve is therefore required for each such fire sprinkler system. In structures with large floor plates, control valves are provided at each floor level.

2007 California Fire Code (CFC) Section 903.4.3; NFPA 13-2002 Section 8.2.1
2010 California Fire Code (CFC) Sections 903.3.8 and 903.4.3; NFPA 13-2013 Section 8.2.1
2013 California Fire Code (CFC) Sections 903.3.8 and 903.4.3; NFPA 13-2013 Section 8.2.1
2016 California Fire Code (CFC) Sections 903.3.9 and 903.4.3; NFPA 13-2016 Section 8.2.1
2019 California Fire Code (CFC) Sections 903.3.9 and 903.4.3; NFPA 13-2016 Section 8.2.1
2022 California Fire Code (CFC) Sections 903.3.9 and 903.4.3; NFPA 13-2022 Section 4.4.1

3. Is a safety margin required for fire sprinkler system hydraulic calculations?

Yes. NFPA 13 Standard for the Installation of Sprinkler Systems requires reliable water supply capacity information derived from a water flow test performed within one year of plan submittal. Such test must be further qualified by knowledge of and allowance for available water flow during peak demand conditions.

The NFPA standard allows for alternative means other than a water flow test where drought or other concerns are present. In such situations, the water utility may provide an analysis using knowledge of the flows and pressures in the water system, taking into account peak demand conditions and anticipated development and demand of the community.

When a water flow test or an analysis reflecting peak demand conditions is not available, some reduction is applied to account for peak demand conditions.

To assure an adequate water supply is available for the design and installation of an automatic fire sprinkler system, when a water flow test or an analysis based on peak demand is not available, OSHPD will accept a minimum 10% safety factor between the water supply pressure at the point of connection and the calculated system demand pressure at the point of connection. This safety margin reflects standard industry practice often referred to as a safety factor, cushion or buffer.

2007 California Building Code (CBC) Chapter 35 and NFPA 13-2002 Subsection 14.2.1 & 15.2.1.2
2010 California Building Code (CBC) Chapter 35 and NFPA 13-2010 Subsection 22.2.1.1 & 23.2.1.2
2013 California Building Code (CBC) Chapter 35 and NFPA 13-2013 Subsection 23.2.1.1 & 24.2.2.2
2016 California Building Code (CBC) Chapter 35 and NFPA 13-2016 Subsection 23.2.1.1 & 24.2.2.2
2019 California Building Code (CBC) Chapter 35 and NFPA 13-2016 Subsection 23.2.1.1 & 24.2.2.2
2022 California Building Code (CBC) Chapter 35 and NFPA 13-2022 Subsection 4.5.1.1 & 5.2.2.2

Move to Top

Means of Egress

1. What is HCAI′s position regarding access control devices on the path of the egress doors?

The 2007 California Building Code (CBC) Section 1008.1.3.4 addresses access-controlled egress doors. This section states “The entrance doors in a means of egress in buildings with an occupancy in Group A, B, M, R-1 or R-2 and entrance doors to tenant spaces in occupancies in Groups A, B, M, R-1 and R-2 that are equipped throughout with an automatic sprinkler system in accordance with Section 903.3.1.1 and approved automatic smoke detection system installed in accordance with Section 907, are permitted to be equipped with an approved entrance and egress access control system…” Since Group I occupancies are not included in this list, access-control devices such as card readers or keypads are not permitted on means of egress doors in hospitals. This causes compliance difficulties where the California Department of Public Health (CDPH) Licensing & Certification has requirements for infant security, security in emergency departments, and security in other parts of hospitals.

This provision was revised in the 2010 CBC. OSHPD is interpreting this limitation to apply to exterior doors only. Interior doors may be provided with electronic access-control devices that comply with all of the provisions of Section 1008.1.3.4. For exterior doors, OSHPD will accept compliance with the provisions of the 2010 CBC, Section 1008.1.4.4 as an alternate means of compliance when submitted as an amended construction document.

2007 California Building Code Section 1008.1.3.4

The California Department of Public Health (CDPH), Licensing & Certification has requirements for infant security, security in emergency departments, and security in other parts of hospitals. To accommodate these concerns, OSHPD accepts the 2010, 2013, 2016, 2019 and 2022 California Building Code provisions for the installation of access-controlled egress doors.

The 2016, 2019 and 2022 CBC permit electric locking systems, including electro-mechanical locking systems and electromagnetic locking systems, to be locked in the means of egress in Group I-2 occupancies where the clinical needs of persons receiving care require their containment.

2010 California Building Code (CBC) Section 1008.1.4.4
2013 California Building Code (CBC) Section 1008.1.9.8
2016 California Building Code (CBC) Sections 1010.1.9.6, 1010.1.9.8 and 1010.1.9.9
2019 California Building Code (CBC) Sections 1010.1.9.7, 1010.1.9.9 and 1010.1.9.10
2022 California Building Code (CBC) Sections 1010.2.11, 1010.2.12 and 1010.2.14

2. Does HCAI allow the installation of alcohol-based hand sanitizer dispensers in corridors?

Yes. Alcohol-based hand-rub dispensers are permitted in Group I-2 occupancies in accordance with the California Building Code.

2007 California Building Code (CBC) Section 1003.3.3.1, Exception 2
2010 California Building Code (CBC) Section 1003.3.3.1, Exception 2
2013 California Building Code (CBC) Section 1003.3.3.1, Exception 2
2016 California Building Code (CBC) Section 1003.3.3.1, Exception 2
2019 California Building Code (CBC) Section 1003.3.3.1, Exception 2
2022 California Building Code (CBC) Section 1003.3.3.1, Exception 2

3. Can an information/registration desk be open to a corridor?

Yes. The California Building Code (CBC) permits foyers, lobbies or reception rooms constructed as required for corridors to be open to the corridor. The information/registration desk would be limited to the types of equipment and supplies normally associated with a reception desk. This is generally limited to a telephone and a computer terminal with a very limited amount of combustibles.

2007 California Building Code (CBC) Section 1017.5, Exception 1
2010 California Building Code (CBC) Section 1018.6, Exception 1
2013 California Building Code (CBC) Section 1018.6, Exception 1
2016 California Building Code (CBC) Section 1020.6, Exception 1
2019 California Building Code (CBC) Section 1020.6, Exception 1
2022 California Building Code (CBC) Section 1020.7, Exception 1

4. When remodeling a hospital where the exit passageways contain waiting areas and security desks, do we need to bring all exit passageways into compliance with the current provisions of the CBC?

Code Application Notice (CAN) 2-102.6 (formerly CAN 2-3403A) provides owners, designers and authorized plan review and enforcement agencies with a consistent method for planning, reviewing and implementing projects on existing hospital buildings and systems. Generally, the scope of the project defines the extent of upgrades; however, other factors, such as a remodel that increases the occupant load, may drive upgrades in the means of egress beyond the scope of the project.

5. Are signs located in the means of egress that are provided for room identification and compliance with tactile exit sign requirements regulated for flame spread and smoke development?

Yes. Interior trim with a Class C flame spread and smoke developed index is limited to 10 percent of the specific wall or ceiling area by the California Building Code (CBC). Where such signs are fabricated from plastic laminate material, these signs are typically manufactured with a melamine-based resin and will be at least Class C.

The California Building Code, California Fire Code and NFPA 101 all further qualify requirements regarding the installation of decorative trim by allowing limited quantities of combustibles when they would not contribute to the development or spread of fire. Because, in this case; the signage is discontinuous and each sign is relatively small in area, the likelihood that such signs would contribute to the development or spread of fire is remote and therefore is not a concern.

The 2016, 2019 and 2022 California Fire Code, Section 807.5.3.3 permits in Group I-2, equipped throughout with an approved automatic sprinkler system, combustible decorative materials placed on walls limited to not more than 30 percent of the wall area to which they are attached.

2007 California Building Code (CBC) Sections 806.1 and 806.5; 2007 California Fire Code (CFC) Sections 804.1 and 807.1
2010 California Building Code (CBC) Sections 806.1 and 806.5; 2010 California Fire Code (CFC) Sections 804.1 and 807.1
2013 California Building Code (CBC) Sections 806.1 and 806.5; 2013 California Fire Code (CFC) Sections 804.1 and 807.1
2016 California Building Code (CBC) Sections 806.3 and 806.7, 2016 California Fire Code (CFC) Sections 804.1 and 807.5.3.3
2019 California Building Code (CBC) Sections 806.3 and 806.7, 2019 California Fire Code (CFC) Sections 804.1 and 807.5.3.3
2022 California Building Code (CBC) Sections 806.3 and 806.7, 2022 California Fire Code (CFC) Sections 804.1 and 807.5.3.3
2000 NFPA 101 Sections 10.2.5 and 18.7.5.4
2012 NFPA 101 Sections 10.2.5 and 18.7.5.6

6. Is the installation of a paper towel dispenser permitted at scrub sinks located in a fire-resistance rated corridor?

Yes. Title 19 prohibits combustibles in or exposed to any exit. In this regard, the stated policy of the State Fire Marshal is to be aware of and concerned with intrusions into required exitways. It is not the intent of their enforcement policy to subordinate exitways to a mere convenience of patient care. Rather, their policy is to acknowledge that there are conditions of medical necessity and a continuing evolution in medical care for patients in a hospital environment.

Locating paper towel dispensers at surgical scrub sinks is an essential component of infection control and is therefore a medical necessity and not a mere convenience of patient care. As such, locating paper towel dispensers in corridors in quantities that would not contribute to the development or spread of fire is acceptable where they do not project into the required means of egress width more than 1-1/2” in accordance with the California Building Code.

Title 19, Sec. 3.11 (b)
2007 California Building Code (CBC) Section 1003.3.3.1
2010 California Building Code (CBC) Section 1003.3.3.1
2013 California Building Code (CBC) Section 1003.3.3.1
2016 California Building Code (CBC) Section 1003.3.3.1
2019 California Building Code (CBC) Section 1003.3.3.1
2022 California Building Code (CBC) Section 1003.3.3.1

7. What is the definition of a reception room/area and a foyer? Do foyer and reception rooms/areas have to be at the entrance to a building?

A reception room is a room used for receiving clients, guests, etc. as they arrive. It is not restricted to the entrance of a building.

A foyer is similar to a lobby. A lobby is defined by the California Building Code (CBC) as an area not defined as a waiting room at the entrance of a building through which persons must pass.

2007 California Building Code (CBC) Section 202
2010 California Building Code (CBC) Section 202
2013 California Building Code (CBC) Section 202
2016 California Building Code (CBC) Section 202
2019 California Building Code (CBC) Section 202
2022 California Building Code (CBC) Section 202
Webster’s Third New International Dictionary of the English Language, Unabridged

8. When a corridor is interrupted by a foyer, lobby or reception area, is waiting permitted to occur in these areas?

Yes. In a Group I-2 occupancy, the California Building Code (CBC) permits waiting (seating) in lobbies, foyers and reception areas when these areas are constructed as required for corridors, protected by automatic fire detection, quick-response automatic sprinklers and located so as to permit direct visual supervision by the facility staff.

2007 California Building Code (CBC) Section 407.2.1
2010 California Building Code (CBC) Section 407.2.1
2013 California Building Code (CBC) Section 407.2.1
2016 California Building Code (CBC) Section 407.2.1
2019 California Building Code (CBC) Section 407.2.1
2022 California Building Code (CBC) Section 407.2.1

9. What is the intent of California Building Code (CBC) where it states, “All rooms below grade shall have not less than one exit access that leads directly to an exterior exit door opening directly to an exit discharge at grade plane or the public way.”?

A fire in a basement is inherently more dangerous and more difficult to control. Due to limited access and few exterior openings, fire and smoke use the same stairway paths of escape that are normally used by the basement occupants. At least one exit to grade is essential for the evacuation of patients as well as for access by emergency responders.

When a basement in a Group I-2 contains patient sleeping rooms or inpatient treatment spaces, at least one exit from such basement must exit directly to the exterior at grade plane without the use of an interior exit stairway or ramp. After exiting to grade plane, exterior ramps are permitted as a part of the exit discharge to the public way or a safe dispersal area.

2007 California Building Code (CBC) Sections 1014.2.2.1 and 1023.2
2010 California Building Code (CBC) Sections 1014.2.2.1 and 1026.2
2013 California Building Code (CBC) Sections 407.4.1.2, 1014.2.2 and 1026.2
2016 California Building Code (CBC) Sections 407.4.1.2, 1016.2.2 and 1027.2
2019 California Building Code (CBC) Sections 407.4.1.2, 1016.2.2 and 1027.2
2022 California Building Code (CBC) Sections 407.4.1.2, 1016.2.2 and 1027.2

10. Is emergency power required for means of egress illumination of the exterior exit discharge to the public way?

Yes. The 2019 and 2022 California Building Code require means of egress illumination for the exterior exit discharge to the public way or a safe dispersal area. Previous editions of the California Building Code required emergency power for means of egress illumination of the exterior exit discharge only at exterior door landings. However, emergency power for the exterior exit discharge means of egress illumination remained a concern.

Emergency lighting for the exit discharge is a requirement for licensing and accreditation of health facilities regulated or accredited by the Centers for Medicare & Medicaid Services (CMS), The Joint Commission (TJC) and the California Department of Public Health (CDPH), Licensing and Certification Program (L&C).

NFPA 101 requires emergency lighting for the exit discharge only for designated stairs, ramps, aisles, walkways, and escalators leading to a public way. Additional information in the NFPA 101 Annex further clarifies that emergency lighting provided outside the building should extend to either a public way or a distance away from the building that is considered safe; whichever is closest to the building being evacuated.

It should therefore be expected that a project that includes the construction or alteration of an exterior exit discharge will include emergency lighting for the exit discharge to the public way or a safe dispersal area. When this occurs, emergency lighting shall be reviewed and inspected for compliance with the California Building Code and the California Electrical Code.

2007 California Building Code (CBC) Section 1006.3, Item 5
2010 California Building Code (CBC) Section 1006.3, Item 5
2013 California Building Code (CBC) Section 1006.3, Item 5
2016 California Building Code (CBC) Section 1008.3.2, Item 5
2019 California Building Code (CBC) Section 1008.3.2, Item 6
2022 California Building Code (CBC) Section 1008.3.2, Item 6
2000 NFPA 101 Sections 18.2.9.1, 7.9.1.1 and 7.9.1.2 and Annex Section A.7.9.1.1
2012 NFPA 101 Sections 18.2.9.1, 7.9.1.1 and 7.9.1.2 and Annex Section A.7.9.1.1

11. Is the circulation space within a care-suite a corridor?

The circulation space within a care suite, adjacent to the treatment spaces, is a corridor. CBC 1020.1, Exception 6 allows for the corridor portion of suites, designed in compliance with CBC 407.4.4 or 407.4.5, to be non-rated.

Therefore, if the design of the care suite appears to create a corridor with wall partitions rather than a large open room, the design shall comply with corridor requirements within CBC Chapter 10 and CBC 1020.1 Exception 6.

12. Are Perimeter Supporting Clips acceptable for use in care-suites?

Yes. The corridor within a care-suite designed in accordance with CBC 1020.1 exception 6 and does not require one hour fire rated partitions for the corridor, but if the layout is designed with wall partitions that appear to function as a corridor the requirements for corridors apply.

If the width of a non-rated corridor is less than 12 feet, perimeter supporting clips cannot be utilized and shall comply with CBC 1617A.1.21 unless an OPM that allows it is used.

If the ceiling grid within the non-rated corridor in the care-suite is greater than 12 feet in width, perimeter supporting clips are acceptable for use and shall be installed in accordance with ASCE 7-16.

Move to Top

Miscellaneous

1. Is an underground tank installation permitted within a side yard?

Yes. The California Fire Code (CFC) regulates the location of flammable and combustible liquid storage tanks located underground, either outside or under buildings. The California Building Code (CBC) states that for the purpose of calculating a frontage increase, such yard shall be considered as an open (unobstructed) space when the underground tank installation is in accordance with the CFC.

2007 California Building Code (CBC) Section 506.2 and 2007 California Fire Code (CFC) Sections 3404.2.11.2 and 3404.2.11.3
2010 California Building Code (CBC) Section 506.2 and 2010 California Fire Code (CFC) Sections 3404.2.11.2 and 3404.2.11.3
2013 California Building Code (CBC) Section 506.2 and 2013 California Fire Code (CFC) Sections 5704.2.11.2 and 5704.2.11.3
2016 California Building Code (CBC) Section 506.3 and 2016 California Fire Code (CFC) Sections 5704.2.11.1 and 5704.2.11.2
2019 California Building Code (CBC) Section 506.3 and 2019 California Fire Code (CFC) Sections 5704.2.11.1 and 5704.2.11.2
2022 California Building Code (CBC) Section 506.3 and 2022 California Fire Code (CFC) Sections 5704.2.11.1 and 5704.2.11.2

Move to Top

Fire and Life Safety (FLS) Frequently Asked Questions

Fire and Life Safety General#

1. Who decides what fire alarm and fire sprinkler deferred submittal documents can be reviewed in the field?#

2. What are the code requirements for temporary construction barriers?#

3. Can a licensed specialty contractor prepare construction documents for a project consisting only of a fire sprinkler system?#

4. As used in Code Application Notice CAN 2-703.3, what does the term “manufacturer′s qualified technical personnel” mean?#

5. Which sheets of the construction documents should contain the details for temporary construction barriers: demolition sheets, architectural sheets, both?#

6. Temporary construction barrier partitions are often built in the existing corridors (parallel with the corridor walls). What are HCAI′s recommendations for permissible corridor width for this interim condition?#

7. Who can submit (stamp) deferred approval fire sprinkler or fire alarm construction documents for projects in health care facilities?#

8. For a remodel of a limited area of a healthcare facility, how should hazardous materials inventories be categorized?#

Fire and Life Safety Smoke Barriers#

1. Are smoke compartment walls required to be provided in ground level lobbies?#

2. Smoke zones are required to be 150 feet maximum in length or width but HCAI is interpreting that to mean both length and width. As long as compartment size is less than 22,500 square feet, does the length or width need to be limited?#

3. Is each door in a smoke barrier partition, other than cross-corridor doors, required to be provided with an electric hold-open device in addition to the “self-closing” door closer (such as a janitor closet door or bathroom door)?#

4. In Group I-2, I-2.1 and ambulatory care facilities, where doors are installed across a corridor, are a pair of opposite swinging doors required?#

Fire and Life Safety Fire Resistant Materials and Construction#

1. In buildings of Type I or II construction, is a fire block required at the corridor ceiling?#

2. When is a T-Rating required for penetrations?#

3. Is the dimension for the edge-of-slab to the face of the exterior “curtain wall” required to comply with UL exterior wall perimeter fire containment systems?#

4. Are there listed fire assemblies for tube steel beams?#

5. For interior walls of one-hour fire resistive construction where opening protection is not required, is it permissible for the wallboard to terminate just above the ceiling?#

6. When must upholstered furniture comply with the regulations of the Bureau of Electronic and Appliance Repair, Home Furnishings and Thermal Insulation?#

7. Are through-penetration firestop and membrane penetration details required on construction documents?#

8. Does a storage room with a floor area greater than 100 sq. ft. require separation and protection?#

9. Do openings located in Type V-A eave projections require protection?#

10. When do bracing members require fire resistive protection in accordance with the requirements for the primary structural frame?#

11. What training for special inspection agencies and special inspectors is acceptable for special inspections of fire-resistance penetrations and joints?#

Fire Alarm#

1. Are conduits and boxes allowed to be installed prior to HCAI′s approval of a fire alarm deferred submittal?#

2. Where should the pull station be located in relationship to an exit?#

3. Does HCAI accept the use of driven pins for the support of fire alarm conduits?#

4. In Group I Occupancies, are fire alarm notification devices required to be designed and installed in accordance with the NFPA 72 provisions for Public Mode or for Private Mode?#

5. Are fire alarm notification devices required in operating rooms?#

6. Are there specific health care related areas or uses where visible fire alarm notification appliances are required?#

Fire/Smoke Dampers (FSD)#

1. Can a horizontal FSD be used at the top of a shaft or does a rated enclosure “dog house” need to be constructed so the installation of a vertical FSD can be used?#

2. Does each smoke fire damper require individual service power disconnecting means?#

Fire Sprinkler Protection#

1. How current must water supply capacity information that is provided with a fire sprinkler system design submittal be?#

2. When is a fire sprinkler system floor control valve required?#

3. Is a safety margin required for fire sprinkler system hydraulic calculations?#

Means of Egress#

1. What is HCAI′s position regarding access control devices on the path of the egress doors?#

2. Does HCAI allow the installation of alcohol-based hand sanitizer dispensers in corridors?#

3. Can an information/registration desk be open to a corridor?#

4. When remodeling a hospital where the exit passageways contain waiting areas and security desks, do we need to bring all exit passageways into compliance with the current provisions of the CBC?#

5. Are signs located in the means of egress that are provided for room identification and compliance with tactile exit sign requirements regulated for flame spread and smoke development?#

6. Is the installation of a paper towel dispenser permitted at scrub sinks located in a fire-resistance rated corridor?#

7. What is the definition of a reception room/area and a foyer? Do foyer and reception rooms/areas have to be at the entrance to a building?#

8. When a corridor is interrupted by a foyer, lobby or reception area, is waiting permitted to occur in these areas?#

9. What is the intent of California Building Code (CBC) where it states, “All rooms below grade shall have not less than one exit access that leads directly to an exterior exit door opening directly to an exit discharge at grade plane or the public way.”?#

10. Is emergency power required for means of egress illumination of the exterior exit discharge to the public way?#

11. Is the circulation space within a care-suite a corridor? #

12. Are Perimeter Supporting Clips acceptable for use in care-suites? #

Miscellaneous#

1. Is an underground tank installation permitted within a side yard?#

Fire and Life Safety General

1. Who decides what fire alarm and fire sprinkler deferred submittal documents can be reviewed in the field?

2. What are the code requirements for temporary construction barriers?

**3. Can a licensed specialty contractor prepare construction documents for a project consisting only of a fire sprinkler system?**

4. As used in Code Application Notice CAN 2-703.3, what does the term “manufacturer′s qualified technical personnel” mean?

5. Which sheets of the construction documents should contain the details for temporary construction barriers: demolition sheets, architectural sheets, both?

6. Temporary construction barrier partitions are often built in the existing corridors (parallel with the corridor walls). What are HCAI′s recommendations for permissible corridor width for this interim condition?

7. Who can submit (stamp) deferred approval fire sprinkler or fire alarm construction documents for projects in health care facilities?

8. For a remodel of a limited area of a healthcare facility, how should hazardous materials inventories be categorized?

Fire and Life Safety Smoke Barriers

1. Are smoke compartment walls required to be provided in ground level lobbies?

2. Smoke zones are required to be 150 feet maximum in length or width but HCAI is interpreting that to mean both length and width. As long as compartment size is less than 22,500 square feet, does the length or width need to be limited?

3. Is each door in a smoke barrier partition, other than cross-corridor doors, required to be provided with an electric hold-open device in addition to the “self-closing” door closer (such as a janitor closet door or bathroom door)?

4. In Group I-2, I-2.1 and ambulatory care facilities, where doors are installed across a corridor, are a pair of opposite swinging doors required?

Fire and Life Safety Fire Resistant Materials and Construction

1. In buildings of Type I or II construction, is a fire block required at the corridor ceiling?

2. When is a T-Rating required for penetrations?

3. Is the dimension for the edge-of-slab to the face of the exterior “curtain wall” required to comply with UL exterior wall perimeter fire containment systems?

4. Are there listed fire assemblies for tube steel beams?

5. For interior walls of one-hour fire resistive construction where opening protection is not required, is it permissible for the wallboard to terminate just above the ceiling?

6. When must upholstered furniture comply with the regulations of the Bureau of Electronic and Appliance Repair, Home Furnishings and Thermal Insulation?

7. Are through-penetration firestop and membrane penetration details required on construction documents?

8. Does a storage room with a floor area greater than 100 sq. ft. require separation and protection?

9. Do openings located in Type V-A eave projections require protection?

10. When do bracing members require fire resistive protection in accordance with the requirements for the primary structural frame?

11. What training for special inspection agencies and special inspectors is acceptable for special inspections of fire-resistance penetrations and joints?

Fire Alarm

1. Are conduits and boxes allowed to be installed prior to HCAI′s approval of a fire alarm deferred submittal?

2. Where should the pull station be located in relationship to an exit?

3. Does HCAI accept the use of driven pins for the support of fire alarm conduits?

4. In Group I Occupancies, are fire alarm notification devices required to be designed and installed in accordance with the NFPA 72 provisions for Public Mode or for Private Mode?

5. Are fire alarm notification devices required in operating rooms?

6. Are there specific health care related areas or uses where visible fire alarm notification appliances are required?

Fire/Smoke Dampers (FSD)

1. Can a horizontal FSD be used at the top of a shaft or does a rated enclosure “dog house” need to be constructed so the installation of a vertical FSD can be used?

2. Does each smoke fire damper require individual service power disconnecting means?

Fire Sprinkler Protection

1. How current must water supply capacity information that is provided with a fire sprinkler system design submittal be?

2. When is a fire sprinkler system floor control valve required?

3. Is a safety margin required for fire sprinkler system hydraulic calculations?

Means of Egress

1. What is HCAI′s position regarding access control devices on the path of the egress doors?

2. Does HCAI allow the installation of alcohol-based hand sanitizer dispensers in corridors?

3. Can an information/registration desk be open to a corridor?

4. When remodeling a hospital where the exit passageways contain waiting areas and security desks, do we need to bring all exit passageways into compliance with the current provisions of the CBC?

5. Are signs located in the means of egress that are provided for room identification and compliance with tactile exit sign requirements regulated for flame spread and smoke development?

6. Is the installation of a paper towel dispenser permitted at scrub sinks located in a fire-resistance rated corridor?

7. What is the definition of a reception room/area and a foyer? Do foyer and reception rooms/areas have to be at the entrance to a building?

8. When a corridor is interrupted by a foyer, lobby or reception area, is waiting permitted to occur in these areas?

9. What is the intent of California Building Code (CBC) where it states, “All rooms below grade shall have not less than one exit access that leads directly to an exterior exit door opening directly to an exit discharge at grade plane or the public way.”?

10. Is emergency power required for means of egress illumination of the exterior exit discharge to the public way?

11. Is the circulation space within a care-suite a corridor?

12. Are Perimeter Supporting Clips acceptable for use in care-suites?

Miscellaneous

1. Is an underground tank installation permitted within a side yard?