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Permit • A: CITY OF TIGARD BUILDING PERMIT PERMIT #: BUP2005 -00109 k DEVELOPMENT SERVICES DATE ISSUED: 3/30/2005 ' �' I 13125 SW Hall Blvd., Tigard, OR 97223 503 - 639 -4171 PARCEL: 2S115AA -OTOOA SITE ADDRESS: 16215 SW 108TH AVE BLDG D ZONING: R -25 SUBDIVISION: OAK TREE APARTMENTS LOT: OOA JURISDICTION: TIG Project Description: Building D, fire alarm. REISSUE: FLOOR AREAS EXTERIOR WALL CONSTRUCTION CLASS OF WORK: FPS FIRST: sf N: S: E: W: TYPE OF USE: MF SECOND: sf PROJECT OPENINGS? TYPE OF CONST: 5 -1HR : sf N: S: E: W: OCCUPANCY GRP: R1 TOTAL AREA: 0 sf ROOF CONST: FIRE RET? OCCUPANCY LOAD: BASEMENT: sf AREA SEP. RATED: STOR: 3 HT: ft GARAGE: sf OCCU SEP. RATED: BSMT ?: MEZZ ?: REQD SETBACKS REQUIRED FLOOR LOAD: psf LEFT: ft RGHT: ft FIR SPKL: SMOK DET: DWELLING UNITS: FRNT: ft REAR: ft FIR ALRM : HNDICP ACC: BEDRMS: BATHS: IMP SURFACE: PRO CORR: PARKING: VALUE: $ 4,000.00 Owner: Contractor: OT2 LLC FIRE & SECURITY GROUP LLC 5437 ROSALIA WAY SUITE 100 2538 NE EVERETT ST LAKE OSWEGO, OR 97035 CAMAS, WA 98607 Phone: 503 - 620 -4373 Phone: 360- 833 -9938 FEES Reg #: LIC 153226 Description Date Amount REQUIRED ITEMS AND REPORTS [BUILD] Permit Fee 3/30/2005 $81.70 [TAX] 8% State Surcharl 3/30/2005 $6.54 [FLS] FLS Pln Rv 3/30/2005 $32.68 Total $120.92 This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of these rules or direct questions to OUNC by calling 503 - 246 -6699 or 1- 800 - 332 -2344. Issued By: 4 .1.. , 2,- Permittee Signature: 'tilv ___ Call 503 -639 -4175 by 7:00 a.m. for an inspection that business day. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. r' Fire-Protection System Building Permit Application FOR OFFICE USE ONLY City of Tigard s N o.: p % , f , 13125 SW hall Blvd., Tigard, OR 97223 Pik j i / Plan Review • �/ , DatrlB ((�S/ p er Pemut )0 - 0011/0 Phone: 503.639.4171 Fax: 503.598.1960 a .. , i Date/Br � S �c�fJ 7 Inspection Line: 503.639.4175 T ' -''- i A ! -' ti foci• f Z X g)',// { 11165' g e 2 for 0 Set Internet: www.ci.tigar3.or.us 41[Y .OF TIGARI '- Supplemental Information BUILDING ,DIVISION S O K - e W/ eL,k ;., rY'v',,, " , ;y�;�.r. ',��.'i s' ' s `. '*r',s' < y „ ' ..�Fs t : � ; '% Ski ! " " ': •r r r rix"� �*- . f ir y y ,,a� ,� Y y r'.:.u�3' , x'3'} Print name: Richard C. ,`StCYC7i40n s���" - . ` � '' m ' �+ • -,, 1 ..... �.:s'04 3 . {� a:y4 r r r:f , rf, t 0 New construction El Demolition , , I � , rg 4 � i + r 41 's [f Addition/alteration/replacement ❑ Other Permit fees* are based on the value of the work performed. t; A-,: � , Indicate the value (rounded to the nearest. dollar) of all , �y s �� i may- Wig. '" .c£; s s i k <i 7 - 't ` r� ' 5 i 0 - , „ '„`' — ..,s• w , . {: materials, labor, overhead, and the profit for the work indicated on this application. ❑ 1- and 2-family dwelling El Commercial/industrial Valuation: $ ❑ Accessory building ® Multi - family ❑ Master builder 0 Other Number of bedrooms: :. " " 'r,. .4." 9;:%.,•.'•., %3s '-,� �3%i?; {vsv'% q ,, � � �s� � � �,� � � f �`-�� i s --�:�. £ Number of bathrooms' Y ,r � . W < „< ,.. .�, te r: .., . c,.,<.. � ...... � ., . ... .. ::t.'i :w' /i. Job site address: i t A (S s t t 2 / 0 4 T Total numberof floors: City/State/ZIP: Tim, x'97224 / /,4 „60 New dwelling area square feet Suite/bldgiapt no.: I Project name: Oak Tree Apartments G area: square feet Cross street/directions to job site SE 108 & Durant Rd. Covered porch area: sgitate feet Deck area square feet Other structure area: square feet Subdivision: `Lot no.: ,� �D A M 11174 ?c ” n Tax map/parcel no.: Permit fees* are based on the value of the work performed. y. = :.w _r f -F, _ Indicate-the value ( roundedtc ► the - nearest dollar) ofall "rte % =.:s. ti :�' � r . i ,/. ' : =,"' �w s y:sq`>. ti +'� s %,- _, � f..<, ., .. � '� �'��� ..' -�. �� 4 .• >-% ��� =�'r- {`%::�,;:..;:.= �::.:�:: -_ a ..,,. equipment, materials, labor, overhead, and the profit for the Fire Alarm Install for 5 bldg& 3 stt►r#es each for sprhdder system monitoring and work indicated on this application. notification Valuation: 1 l'0OO• t (, Existing building area square feet New building area: square feet &:P,i it =. = c'z = :w Skti'c':a .� a >t.i '�itsv f. 4 . stories: 3 ., Number of sto . =:,<. rs.... <..: : r „..., y,,.,.,: .�... =..�9j"c,4, Name: Type of construction: V -1 Address: Occupancy groups City/State/ZIP: Existing: Phone: ( ) Fax: ( ) V -I. .. - =t =:;: ;.:...•:_� ';:...�:•..:;�,.,. New: '- /.i!c6'1:;. 4 {.: ".�. .i�: „� *.Y...reesnr::v.•.., ;.,�� i rJ�''ts,. ,r�i�s% 'lr/ -:.f, , , p�y t V... .. ^ t•JC'2:r. <•r -0, ... �, .tko �1el . '',11 �d . Kt.:4, V;¢ %: j- ; 335 J., f.,' % == ?t_:�....... �. N,ll: 4so. %:.¢ %c /.��. i.4,� fc /i l,f....+i..�'__' .. Business name: Fire e & Security Group LLC All contractors and subcontractors are required to be " Contact name: Rick Stevenson licensed with the Oregon Construction Contractors Board under ORS 701 and maybe required to be licensed in the Address: 2538 NE Everett Street jurisdiction in which work is being performed. If the City/State/ZIP: 98607 applicant is exemptfrom licensing, the following reasons apply: Phone: (360) 833 -9938 I Fax: : (360).833 -1727 E -mail: n e *-see[ Eggroap.com , �4 Business name: Fire & Security Group LLC . ---- =:. �t Address: 2538 NE Everett Street Please refer lo feesclre City/State/ZIP: Camas, WA. 98607 Fees due upon application Phone: (360) 833 -9938 Fax (360)833-1727 Amount received CCB lic. : 153226 Date received: Authorized signature: This permit application expires if a permit is not obtained whisk 180 days after it has been accepted as complete. CITY OF TIGARD f Zp0 5- 00 t 0q BUILDING DIVISION PERMIT #: 13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: Phone: (503) 639 -4171 Aso 11111iiillfl1�'I� Inspection Requests (24 Hrs.): (503) 639 -4175 - _L INSPECTION WORKSHEET FOR DATE: I /75 /6 J TIME: PAGE: SITE ADDRESS: I lQ ii , tog 6 ` D b Y CLASS OF WORK: SUBDIVISION: LOT #: TYPE OF USE: PROJECT NAME: DESCRIPTION: OWNER: PHONE #: CONTRACTOR: PHONE #: Inspection Request Scheduled For: Date: Pour Time: Code # Inspection Description Confirm # Contact # Message 6i a_w\ -A-- 1911277 Corrections/Comments/Instructions: Alb I II PASS El PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS ❑ FAIL • CALL FOR INSPECTION ❑ ADDIT ONAL F S ASSESSED Inspector: 0 Date: Phone #: (503) 718- CITV.OF TIGARD f IA P2465- 00 i Dct BUILDING DIVISION PERMIT #: I 13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: Phone: (503) 639 -4171 iv"� (lA Inspection Requests (24 Hrs.): (503) 639 - 4175 INSPECTION WORKSHEET FOR DATE: I 0 /25 /6 < TIME: PAGE: SITE ADDRESS: I (Q 2-1G i 0 �- L 1 V (l t CLASS OF WORK: SUBDIVISION: LOT #: TYPE OF USE: PROJECT NAME: DESCRIPTION: OWNER: PHONE #: CONTRACTOR: PHONE #: Inspection Request Scheduled For: Date: Pour Time: Code # Inspection Description Confirm # Contact # Message 9 q � f 41 6.42_vv\ --1 rr 6,1 0112-77 - 01 Corrections /Comments /Instructions: ,.r , t 40 1 i i VLK ,A11116._ -A L PASS ❑ PARTIAL APPROVAL ❑ CANCEL n NO ACCESS FAIL ■ CALL FO INSPECTION ❑ ADDITI . NAL FE :S ASSESSED Inspector: ( / / Date: D `� Phone #: (503) 718 - Inspections Required for: U a 0O s' 00/0y F q � (� I ✓ Code I Inspection Description PASS Date By ✓ Code I Inspection Description _ [ PASS Date By BUP - Building Permit ELC - Electrical Permit I - 405 Excavation 105 Underground/slab cover f 410 Fill 110 Temporary electrical service 415 Grading 115 Electrical service /reconnect _ 205 Footing _ 120 Electrical rough -in 805 MFG - Structure grading/footing 125 Wall cover 210 Foundation walls 130 Ceiling cover F 215 Footing drain 135 Low voltage 220 Slab _ 140 Sign installation 310 Crawl chain 145 A/C or heating unit circuit 225 Post/beam structural 150 Hot tub /spa /pool _ 230 Underfloor insulation _ 195 Misc. inspection: 235 Shear walls /anchors 199 Electrical final _ 240_ Exterior sheathing _ 245 Firewall ___ 250 Roof nailing ELR - Restricted Energy Permit _ 255 ! Wtr roofing basement walls 135 Low voltage __ , 260 Tilt -up panel 195 Misc. inspection: 265 Masonry 199 Electrical final ' 270 Reinforcing steel (rebar) 275 Framing 810 MFG- Structure set -up MEC - Mechanical Permit 280 Insulation 605 Post/beam mechanical _ 285 Drywall nailing _ 610 Gas line — 287 Suspended ceiling 615 Mechanical rough -in — —I 295 Misc. inspection: 620 Hydronic piping 899 MFG - Structure final 625 Duct work I 498 Grading final 630 Fire damper 0 . 299 Final inspection _ 635 Smoke detector shutdown _ 640 Exhaust hood 695 Misc. inspection: 699 Mechanical final _ t BUP - Fire Protection System Permit 905 Sprinkler underfloor /slab PLM - Plumbing Permit 910 Sprinkler rough -in 305 Plumbing underslab X 915 Fire alarm rough -in 310 Crawl drain 920 Suppression trip test 315 Post/beam plumbing +� 995 Misc. inspection: 320 Plumbing rough in x 998 Alarm final 325 RP/backflow preventer 999 Sprinkler final 330 Water service ' 335 Rain drain 340 Storm drain a SIT - Site Work Permit - _ 505 Sanitary sewer I 405 Excavation — I 345 Culvert/catch basin _ 410 Fill 350 Septic tank • 415 Gradii g _ _ 395 Misc. inspection: 205 Footing 399 Plumbing final 210 Foundation walls 215 Footing drain 420 Sprinkler supply lines SWR - Sewer Permit _ _ 1 _ i 495 Misc. inspection: 505 Sanitary sewer - 1 498 Grading final 595 Misc. inspection: _ �- j 499 Final inspection 599 Final inspection J I :\Building \IVR \InspCard- AOP.doc 02/02/2005 • C ITY OF TIGARD BUILDING PERMIT PERMIT #: BUP2005 -00109 1- ��j - 13125 DEVELOPMENT H BMENg Tigard, -639 -4171 DATE ISSUED: 3/3012005 PARCEL: 23 115AA -OTOOA SITE ADDRESS: 16215 SW 108TH AVE BLDG D ZONING: R -25 SUBDIVISION: OAK TREE APARTMENTS LOT: OOA JURISDICTION: TIG Project Description: Building D, fire alarm. REISSUE: FLOOR AREAS EXTERIOR WALL CONSTRUCTIO CLASS OF WORK: FPS FIRST: sf N: S: E: W: TYPE OF USE: MF SECOND: sf PROJECT OPENINGS? TYPE OF CONST: 5 -1 HR : sf N: S: E: W: V1 OCCUPANCY GRP: R1 TOTAL AREA: 0 sf ROOF CONST: FIRE RET? OCCUPANCY LOAD: BASEMENT: sf AREA SEP. RATED: STOR: 3 HT: ft GARAGE: sf OCCU SEP. RATED: BSMT ?: MEZZ ?: REQD SETBACKS REQUIRED FLOOR LOAD: psf LEFT: ft RGHT: ft FIR SPKL: SMOK DET: DWELLING UNITS: FRNT: ft REAR: ft FIR ALRM : HNDICP ACC: BEDRMS: BATHS: IMP SURFACE: PRO CORR: PARKING: VALUE: $ 4,000.00 Owner: Contractor: OT2 LLC FIRE & SECURITY GROUP LLC 5437 ROSALIA WAY SUITE 100 2538 NE EVERETT ST LAKE OSWEGO, OR 97035 CAMAS, WA 98607 Phone: 503- 620 -4373 Phone: 360- 833 -9938 — FEES Reg #: LIC 153226 Description Date Amount REQUIRED ITEMS AND REPORTS irgi [BUILD] Permit Fee 3/30/2005 $81.70 [TAX] 8% State Surcharl 3/30/2005 $6.54 [FLS] FLS Pin Rv 3/30/2005 $32.68 Total $120.92 !\ 0. • I 1 This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes t and all other applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more than 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 - 0100. You may obtain a copy of these rules or direct questions to OUNC by 4 6 calling 503-246-6699 or 1-800-332-2344. / #/ • Issued By: . ,,L.- - ; ,hyt r ^,r,„ ' Permittee Signature: /4 X / L . ` M iii o Call 503 - 639 -4175 by 7:00 a.m. for an inspection that business day. This permit card shall be kept in a conspicuous place on the job site until completion of the project. Approved plans are required on the job site at the time of each inspection. 1 ' • ARE ALARM SYSTEM RECORD OF COMPLETION Name of protected property. ®o` e 7 Addrr_ss: /( /$ �' S g "Yew- / • © 2-7170 Representative of protected property (name /phone): J' r y t ' j C. ewe, Std 3 - 4 411 - Authority having jurisdiction: �/, rir T c^•' c� Address /telephone number:. / 5/i 1 — - /4 l/ 1. Type(s) of System or Service NFPA 72. Chapter 3 — Local / �^ If alarm Is trans tnitted to location(s) off premises. list where received: `��" Tr e' / NFPA 72. Chapter 3 — Emergency Voice /Alarm Service ,4 "4i t _ Quantity of voice/alarm channels: Single: Multiple: Quantity of speakers installed: Quantity of speaker zones: Quantity of telephones or telephone jacks included in system: .v NFPA 72, Chapter 6 — Auxiliary indicate type of connection): Local energy Shunt Parallel. telephone Location of telephone number for receipt of signals: C. 5 1 f 2 --7 Z 2"' O 5 t NFPA 72. Chapter 5 — Remote Station Alarm Supervisory: NFPA 72. Chapter 5 — Proprietary If alarms are retransmitted to public fire service communications centers or others. indicate location and telephone numbers of the organization receiving alarm: lncllcatt: how a larm is retransmitted: __ NFPA 72. Chapter 5 — Central Station ^ Prime contractor � t ' - f 6r 'rr / l.� a";) Central station location C ` 5 L" 37 J 5 w /'f>" 4`O? C Means of transmission of signals from the protected premises to the central station: McCupah Multiplex One -way radio Digital alarm communicator Two-way radio Others Mean of mission ' alarms to the public fire service communications center: Re_ .i- Ieaataa: C-- sus (IiF t► Rowed el Ceemision , a 41 • Figure 1-6.2.1 (Continued) http: / /www.nfpa.org/codesoniine/ document. asp? action= load&scop &Path =NFPA /codes/n... 520/02 al6G at, ui JJ (f) Visual signal Type: with audible w/o audible (g) Local annunciator 7. Signaling Line Circuits Quantity and class (see NFPA 72, Tabk 3-6)91 signaling line circuits connected to system: Quantity: Style: Class: • 8. System Power Supplies (a) Primary (main): I z© 6 4 4 4- Nominal voltage: I / ` L//`Current racing Overcurrent protection: Type: Current rating: Location. rip I ?7,e (b) Secondary (standby): • � Storage battery: Amp -hour rating: 1- 7 A A / Calculated capacity to chive system, in hours: _ 24 _ 60 Engine- driven generator dedicated to fire alarm system: Location of fuel storage: (c) Emergency or standby system used as backup to primary power supply instead of using a secondary power supply: Emergency system described in NFPA 70, Article 700 Legally required standby system described in NFPA 70, Article 701 Optional standby system described in NFPA 70, Article 702, which also meets the performance requirements of Article 700 or 701 9. System Software (a) Operating system software revision level(s): (b) Application software revision level(s): (c) Revision completed by.. /( bowl Oirro) 10. Comments: (sipped) for central station or alarm service company or installation a ntractorfsupp1Ye (titir) _ (date) Frequency of routine tests and inspections. if other than in accordance with the referenced NFPA standard(s): System deviations from the referenced NFPA standard(s) are: (signed) for central station or alarm service company or installation crntractoSsuppiier (tide) (date) Upon completion of the system(s) satisfactory test(s) witnessed (if requited by the authority having jurisdiction): (signed) of the authority laving)urisdlegon (tltk) (date) 1- 6.2.1.1 All fire alarm systems that are modified after the initial installation shall have the original record of completion revised to show all changes from the original information and shall include a revision date. http : / /www.nfpa.org/codesonline/ document. asp? action= load &scop = 2 &path= NFPA/codes/n... 920/02 • y i p (d) Sprinkler waterfiow switches: Transmitters Noncoded. activating Coded (e) Other (list): 5. Supervisory Signal- Initiating Devkms and Circuits (use blanks to indicate query of devices) GUARDS TOUR (a) Coded stations (b) Noncoded stations, activating transmitters (c) Compulsory guard tour system comprised of transmitter stations and intermediate stations Note: Combination devices are recorded under 4(b) and 5(a). SPRINKLER SYSTEM (a) Coded valve supervisory signaling attachments - Value supervisory switches. activating transmitters (b) Building temperature points (c) . Site water temperature points (d) Site water supply level points Electric fire pump: (e) Fire pump power (� Fire pump running (g) Phase reversal Engine-driven fire pump: (h) , Selector in auto position (i) Engine or control panel trouble (j) Flre pump r Engine- driven generator (k) Selector in auto position (1) Control panel trouble (jet) Transfer switches (n) Engine running Other supervisory function(%) (specify): 6. Alarm Notification Appliances and Circuits Quantity and class (sty NFPA 72, Table 3 -7) of notification appliance circuits connected to the system Types and quantities of notification appliances installed: Quantity: Style: Claw (a) Bells .Itch (b) Speakers (c) / U Horns (d) Chimes (e) Other: Figure 1-6.2.1 (Continued) http: / /www.nfpa.org/codesonline /document. asp? action= load &scop = 2 &oath= NFPA/codes/n... 5/20/02 t, Ot �mel o� Installer • L f .') te.. G -►^ea. 7 esea l ative _ 36.0 - 83 3 - ggSy Supplier Service organization ' 5A4A -- C Location of record (as- built) drawings: ( -1J Lo NA oLi S Location of owners manuals: e_ I r! 14 laQrl -e-- Location of test reports: A contract, dated . for test and inspection In accordance with NFPA standard(s) No(s). .A . dated , is in effect. 2. Record of System Installation (Fill out after Installation is complete and wiring checked for opens. shorts, ground faults. and improper branching, but prior to conducting operational acceptance tests.) This tern has been Installed in with the NFPA standards as shown below was inspected by ,a 5`revia , -(e4 on _l /0 . includes the devices shown below, and has been in service since _ NPPA 72. Chapters ®f) 3 4) 5 ©7 (circle all that ePPIY) NITA T0, National Electrical Code, Article 760 Manufacturer's instructions Other (specify): Signed: Date: Organization: 3. Record of System Operation All operational features and functions of this system were tested by lee' ksr -- sue // / d and found to be operatinTp0 In accordance with the requirements of _C._ NFPA 72, Chapters 3 t 5 6 7 (circle all that apply) • ..„X ,, NFPA 70, National Electrical Code, Article 760 Manufacturer's instructions si r :Iw�/ !1.: pate: ///742/e9. Organization= Ord J — 5e — e - U - C" - -- , "- , 4. Al arm - Initiating Devices and Circuits Quantity and class of initiating device circuits (see NPPA 72, Table 3 -5) Quantity: Style Class: MANUAL (a) Manual stations Noncoded, activating Transmitters _ Coded (b) _ _..., - Combination manual fire alarm and guards tour coded stations AUTOMATIC fns Coverage: C.oznplete: Partial: S� /`, / ( ' c - , f 7 � , / 4'5ssi (a) Smoke detectors _ _ Ion - Photo (b) Duct detectors Ion Photo (c) Heat. detectors FT . RR FT/RR , RC Figure 1-6.2.1 (Continued) http:// www .nfpa.orgkodesonline/document. asp ?action =load &scope= 2&path- NFPA/codes/n... 5/20/02 Oct 13 05 11:46a Hydro Tech 360 256 2817 Ft . 8 4, • '..71In 01 05 08:06a Hydro Tech 360 256 2817 p.2 \ WASHINGTON STATE FIRE MARSHAL'S OFFICE FIRE SPRINKLER ADVISORY 1 HYDRO TECH FIRE PROTECTION rIVC CONTRACTORS MATERIAL & TEST REPORT FOR ABOVEGROUND PIPING P.O. BOX 40 BRUSH PRAIRIE, WA 98606 .•:::,........--_ .----...-.V.:....=.12.1.7.17.... ..... r.:-......::...,==7.--......-==.7.:-.„-nr...g...,:::-....:-.:-_,,....a.•=r4,,,,,,,,,,„ PROCEDURE Upon completion of work, ktspeCtion and teats shall be made by the contractor's representative and witnessed by an owner's representative. All defects shall be corrected and system left In service before contractor's personnel finally leave the Job. A certificate shall be Sled out and signed by both representatives. Copies shall be prepared for approving authorities, owners, and contractor. It is under- stood the owner's (41:418.entAtiVell signature In no way prejudice; any claim against contractor for faulty material, poor workmanship, of failure to comply with approving authority's requirements or local ordinances. PROPERTY NAME DATE ( 00 11 WIlLGG- 4.0kgritiqarktilS PROPERTY ADDRESS 14:005 . w-•.-.N ‘C4i, A. ZL... b 1 rAtr-ONA T-- ACCF-P ED BY APPROVING AUTHOF_UTIES (NAME) 1 (4)'' CI 1 5 - ADDRESS C.XC e`t c e " L C(t) INSTALLATION CONFORMS TO ACCEPTED PLANS 180[YES LINO PLANS EQUIPMENT USED IS APPROVED YES 0 NO IF NO, EXPLAIN DEVIATIONS _ HAS PERSON IN CHARGE OF FIRE EQUIPMENT SEEN INSTRUCTED AS TO LOCATION 7ELVYS1:31710 OF CONTROL VALVE AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT? W NO EXPLAIN HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES: IiET7Jrz 1. sysrem COMPONENTS INSTRUCTIONS ONO INSTRUCTIONS 2. CARE AND MAINTENANCE INSTRUCTIONS. It ONO 3, NFPA13A RYES ONO LOCATION OF SYSTEM SUPPLIES BUILDINGS WOO 3 eig A■1 e: 6 '• YEAR OF ORIFICE TEMPERATURE' MAKE MODEL MANUFACTURE SIZE QUANTITY RATING ...151MN5Le PA 12,A 4. 2,c,c4.1 '12- 7 54,_> 1 5? SPRINKLERS - - - PIPE AND TYPE OF PIPE CJVC.. FITTINGS TYPE OF FITTINGS C_JVC ALARM ALARM DEVICE MAXIMUM TIME TO OPERATE -. VALVE THROUGH TEST CONNECTION OR FLOW TYPE MAKE MODEL MIN SEC. INDICATOR hif...r.s Ireal. ,111111111CAMOir.14111111•MISEIM111111111=111. DRY VALVE 0.0D. MAKE 1 MODEL 1 SERIAL NO. MAKE MODEL SERIAL NO. ,. ` TIME TO TRIP * TIM WATER ALARM DRY PIPE THRU TEST WATER MR TRIP POINT REACHED OPERATED OPERATING CONNECTION PRESSURE PRESSURE AIR PRESSURE TEST OUTLET PROPERLY ° TEST . TAN_ SEC PSI PSI PSI MIN. SEC. YES NO WITHOUT 1414 O.D.D. WITH . . 0.0.0. IF NO, EXPLAIN • MEASURED FROM TIME INSPECTORS TEST CONNECTION IS OPENED 85A (OVER) Oct 13 05 11:46a Hydro Tech 360 256 2817 p.9 + • 'J!Jn 01 05 08:06a H Tech 360 256 2817 p.3 •PERATION' ❑ PNEUMATIC ❑ ELECTRIC ❑ HYDRAULIC DELUGE 1s PIPING SUPERVISED UYES NO DETECTING MEDIA SUPERVISED yES ^— PREACTION DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATIONS OYES VALVES S THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT FOR TESTING IF NO, EXPLAIN N ❑YES ONO / y 1 DOES EACH CIRCUIT OPERATE ' DOES EACH CIRCUIT MAXIMUM TIME TO I*I MODEL SUPERVISION LOSS ALARM OPERATE VALVE RELEASE . OPERATE RELEASE DESCRIPTION `` Molar hydroatue t..r nude as rW 11.a than soon 1 (I3. buy � • o or 00 �p a OW •l0.. mule pe..yrr. Ill comma a 153 Isl (102 OY.nrtl.f d I 1 .Op.r. •had b. IA ��•v .be..vrauro No1np 1 ••••0• .1W b. mpp.d p u yR em Ea1abl. hr 0 I>✓ Q7 bard sit p•••• ... are measure deep 1k*.h.n.a •.d 1.1R pd 10.1 b•••1in24houa. T..t orwn. l..a.,..rom.1w.w r..� •� •M W m.aa .a• drop tAk1k ah.n t. . .o..c 7 tR ,1 In 2a hati ► U �N i8 T ES TED AT GGr� PSI F ri F - IF NO, STATE REASON 4 RY PIPING PNEUMATICALLY TESTED/AU YES ONO • PMENT OPERATES PROPERLY DYES ONO • • YOU CERTIFY AS THE SPR!NIQER SYSTEM CONTRACTOR THAT ADDITIVES AND CORROSIVE CHEMICALS, SODIUM SILICATE OR DERIVATIVES OF SODIUM SILICATE. BR/NE, OR OTHER CORROSIVE CHEMICALS WERE NOT USED FOR TEST - NG SYSTEMS OR STOPPING LEAKS? OYES ONO TESTS • RAIN I READING OF (SAGE LOCATED NF WATER i i RESIDUAL PRESSURE IMTH V ST t SUPPLY TEST CONNECTION, PSI CONNECTION OPEN WIDE TE PSI I • ERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE TO SPRINKLER PIPING- . • BY COPY OF THE U FORM NO. 858 OYES ONO ( OTHER EXPLAIN FLIED By INSTALLER OF UNDER - - SPRINKLER t+ BLANK TESTING NUMBER USED PIPING �Y ❑ NO GASKETS LOCATIONS NUMBER REMOVED 41!. •ED7PIPING LIVES JNO • • • YOU CERTIFY AS THE SPRINKLER IF YES . THE REOWREMENTS OF AT LEASTTAAWS CONTRACTOR T j LEVEL AR-3 WELDING PROCEDURES COMPLY OYES LINO WELDING '• • YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED IN COMPLIANCE WITH THE REOUTAEMENTS OF AT LEAST AWS D 10.8, LEVEL AR-3 OYES ONO M j ' • YOU CERTIFY THAT IN AT WELDG WAS CARRIED OUT IN COMPLIANCE WITH A J/ j � . • • •• ELATED QUALITY CONTROL PROCEDURE TO INSURE THAT AU. DISCS ARE - 'EVED, THAT OPENINGS IN PIPING ARE SMOOTH. THAT SLAG AND OTHER n • 1-10 RESIDUE ARE REMOVED, AND THAT THE INTERNAL, DIAMETERS OF • /PING ARE NOT PENETRATED OYES ❑ NO . ( k CUTOUTS • • YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL i`F / C (DISCS) ■• OUTS (DISCS) ARE RETRIEVED- OYES ❑ No FUNCTIONAL DOES A14J REQUIRE A FUNCTIONAL FLOW TEST OF RESIDENTIAL SPRINKLERS? FLOWTEST • FUNCTIONAL FLOW TEST RESULTS SATISFACTORY? OYES �d 4 O - • • • .r. • ' NAME PLATE PROVIDED DATA NAMEPLATE NO , EXPLAIN I_ YF_S ONO REMARKS 'ATE LEFT IN SERVICE WIT , • TROL ALVES OPEN E,QF SP ��ONTRACTOR e�� • • NTRAC OR DENSE P VALI Z2.6 t_ Z TESTS WITNESSED BY SIGNATURES • PROPERTY • ER (SIGNED) TITLE GATE .r'ire Co �, 11 44! J . I.„ .. - - . - pRovi , _ LEI,;? 5y.1 tar-- IV TITLE OA E CERTIFY. • T THE ' *=i • r TI • HE - EIN IS TRUE 1 D THAT • S SPRINKLER SYSTEM WAS INSTALLED IN ACCORD - WITH RCVS 18.160 AND THE RULES ADOPTED BY THE WASHINGTON ADMINISTRATIVE CODE AS INISTERED BY CERTIFICATION HE STATE FIRE MARS/- otectio * e ti r a1 p Cortl ticnre � G. I/' 1 (/) . �'1/� - ' ■ AC c °y_M1 e f ce 4 .P O NAME Of CEFMFlCATE O1P G HOIDFR (PRINT On rFFIO ERTITCATE • ac` a , . „. 1. N 31ar1AIt OF CEAr1FICA E OF aouP Etp ---t ? C)5 ExeLmArtoN A.v •area ► e' e:L `' - d a AW F A ar I a y L o r a fh .:, s �.0 V e rou9h Deoem