Report Sep 06 07 11:53a JND FIRE EUGENE 541 687 0239 p.1
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7
CONTRACTOR'S MATERIAL & TEST CERTIFICATE FOR ABOVEGROUND PIPING
PROCEDURE
Upon completion of work, inspection and tests shall be made by the contractor's representative and witnessed by an owner's representative. All defects shall br
Corrected and system left in service before contractor'S personnel finally leave the job.
A certificate shall be filled out and signed by both representatives. Copies shall be prepared for approving authorities, owners, and contractor. It is understood the
owner's representative's signature in no way prejudices any claim against contractor for faulty material, poor workmanship, or failure to comply with approving authority's.
requirements or local ordinances.
PROPERTY NAME c I ' Date / `�` r��
CANTESURY WOODS f ( 6
PROPERTY ADDRESS
/ 6176? 40695&CANTEBURY LANE
ACCEPTED BY APPROVING AUTHORITY CS) NAMES CITY OF TIGARD
ADDRESS _
PLANS INSTALLATION CONFORMS TO ACCEPTED PLANS � YES ❑ NO
EQUIPMENT USED IS APPROVED ® YES ❑ NO
IF NO, EXPLAIN DEVIATIONS
HAS PERSON wl CHARGE OF FIRE EQUIPMENT BEEN OF CONTROL VALVES AND CARE AND MAINTENANCE OF THIS N EQUIPMENT? YES ❑ NO
IF NO, EXPLAIN
INSTRUCTIONS HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES: >:� YES ❑ NO
1. SYSTEM COMPONENTS INSTRUCTIONS ® YES ❑ NO
2. CARE AND MAINTENANCE INSTRUCTIONS ® YES ❑ NO
3. NFPA 13A
LOCATION SUPPLIES BUILDING: #11
OF SYSTEM YEAR OF ORIFICE I TEMPERATURE
■
MAKE MODEL MANUFACTURE SIZE QUANTITY RATING
GLOBE GL -4710 2006 7116" 54 155
GLOBE GL -DRY 2006 1/2" 12 155
SPRINKLERS '
PIPE AND Type of Pipe: CPVC
•
FITTINGS Type of Fittings: CPVC
MAXIMUM TIME TO OPERATE
ALARM DEVICE THRU TEST CONNECTION
ALARM VALVE T YPE MAKE MODEL MIN. SEC. OR FLOW FLOW 1 POTTER VSR -F 0 30
INDICATOR f Q.O.D.
DRY VALVE
MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO.
TIME TO TRIP TRIP POINT TIME WATER ALARM
THRU TEST WATER PRESSURE AIR PRESSURE AIR REACHED OPERATED
CONNECTION' PRESSURE TEST OUTLET' PROPERLY
DRY PIPE MIN. SEC. PSI PSI PSI MIN. SEC. YE NO
❑
OPERATING Without
TEST O.O.O.
With 0 ❑
Q.O.D.
IF NO, EXPLAIN:
'MEASURED FROM TIME INSPECTOR'S TEST CONNECTION OPENED. (OVER)
Sep 06 07 11 :53a JND FIRE EUGENE 541 687 0239 p.2
OPERATION
PNEUMATIC ❑ ELECTRIC ❑ HYDRAULIC
J PIPING SUPERVISED ❑ YES ❑ NO I DETECTING MEDIA SUPERVISED ❑ YES 0 NO
DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATIONS ❑ YES ❑ NO
IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT FOR TESTING IF NO, EXPLAIN
DELUGE & ❑ YES ONO
PREACTION
VALVES
DOES EACH CIRCUIT OPERATE DOES EACH CIRCUIT. OPERATE MAXIMUM TIME TO
MAKE MODEL SUPERVISION LOSS ALARM? VALVE RELEASE? OPERATE RELEASE
YES NO YES NO MIN. SEC.
HYDROSTATIC: Hydrostatic tests shall be made at not less than 200 psi (13.6 bars) for two hours or 50 psi (3.4 bars) above static pressure in excess et 150
TEST Psi (10.2 bars) for two hours. Differential dry -pipe valve clappers shall be left open during test to prevent damage. All aboveground piping leakage shall be
DESCRIPTION Sloes' t
PNEUMATIC: Establish 40 psi (2.7 bars) air pressure and measure drop which shall not exceed 1 -1/2 psi (0.1 bars) in 24 hours. Test pressure tanks at normal
water level and air pressure and measure air pressure drop which shall not exceed 1 -1/2 psi (0.1 bars) in 24 hours.
ALL PIPING HYDROSTATICALLY TESTED AT 200 PSI FOR _2 HRS. IF NO, STATE REASON:
DRY PIPING PNEUMATICALLY TESTED ❑ YES ❑ NO
EQUIPMENT OPERATES PROPERLY ® YES ❑ NO
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT AODITNES AND CORROSIVE CHEMICALS. SODIUM SILICATE OR DERIVATIVES OF
SODIUM SILICATE, BRINE, OR OTHER CORROSNE CHEMICALS WERE NOT USED FOR TESTING SYSTEMS OR STOPPING LEAKS?
TESTS 0 YES ❑ NO •
DRAIN READING OF GAGJ.00ATED NEAR WATER SUPPLY TEST , ROND ION SSUR WITH i VALVE IN TEST
TES CONNECTION: ®® PSI
UNDERGROUND MAIN AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE TO SPRINKLER PIPING
. OTHER EXPLAIN
VERIFIED BY COPY OF THE U FORM NO. 85B ❑ YES ® NO
FLUSHED BY INSTALLER OF UNDER-
GROUND SPRINKLER PIPING ® YES ❑ NO
BLANK NUMBER USED LOCATIONS: NUMBER REMOVED
TESTING 0
GASKETS -
WELDED PIPING ❑ YES ® NO
IF YES...
DO YOU CERTIFY AS THE SPRINIO.ER CONTRACTOR THAT WELDING PROCEDURES COMPLY
WITH THE REQUIREMENTS OF AT LEAST AWS 010.9. LEVEL AR-3? ® YES ❑ NO
DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED IN
COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS 010.9, LEVEL AR-3? ® YES ❑ NO
WELDING
DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A DOCUMENTED
QUALITY CONTROL PROCEDURE TO INSURE THAT AU. DISCS ARE RETRIEVED. THAT OPENINGS
IN PIPING ARE SMOOTH, THAT SLAG AND OTHER WELDING RESIDUE ARE REMOVED, AND THAT ® YES ❑
THE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED? NO
CUTOUTS DO CUTOUTS CERTIFY
S) ARE RETRIEVED? OU HAVE
A CONTROL FEATURE TO ENSURE THAT ALL ®YES ❑ NO
(DISCS)
HYDRAULIC NAME PLATE PROVIDED IF NO, EXPLAIN:
DATA ®YES ONO
NAMEPLATE
DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: `/ I / — 0
L
REMARKS f ((p lJ
NAME OF SPRINKLER CONTRACTOR: JNO FIRE SPRINKLER INC.
TESTS WITNESSED BY
FOR P RTY OWNE-R - ZONED) TITLE DATE
SIGNATURES 2.. _ l A`�+a I �� J J" " ✓►# 4 t t I �� - *a
FOR SP KLER CO CTp�(S ) L rS
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ADDITIONAL EXPLANATION AND NOTES (BACK)