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Report OFFICE COPY '4 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 be 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 Date p � CANTEBURY WOODS �' ( < — C e) PROPERTY ADDRESS /© 7023 CANTEBURY LANE ACCEPTED BY APPROVING AUTHORITY('S) 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 IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION ® YES ❑ NO OF CONTROL VALVES AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT? IF NO, EXPLAIN INSTRUCTIONS HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES: 1. SYSTEM COMPONENTS INSTRUCTIONS ® YES ❑ NO 2. CARE AND MAINTENANCE INSTRUCTIONS ® YES ❑ NO 3. NFPA 13A ® YES ❑ NO LOCATION SUPPLIES BUILDING: #18 OF SYSTEM YEAR OF ORIFICE TEMPERATURE MAKE MODEL MANUFACTURE SIZE QUANTITY RATING GLOBE GL -4710 2006 7/16" 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 TYPE MAKE MODEL MN. SEC. OR FLOW FLOW POTTER VSR -F 0 30 INDICATOR DRY VALVE Q.O.D. 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. YES NO OPERATING Without ❑ ❑ TEST Q.O.D. With ❑ ❑ Q.O.D. IF NO, EXPLAIN: `MEASURED FROM TIME INSPECTOR'S TEST CONNECTION OPENED. (OVER) OPERATION ❑ PNEUMATIC ❑ ELECTRIC ❑ HYDRAULIC PIPING SUPERVISED ❑ YES ❑ NO I DETECTING MEDIA SUPERVISED ❑ YES ❑ NO wIs 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 & PREACTION ❑ YES ❑ NO 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. El ❑ ❑ ❑ , 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 of 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 stopped. 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 ADDITIVES AND CORROSIVE CHEMICALS, SODIUM SILICATE OR DERIVATIVES OF SODIUM SILICATE, BRINE, OR OTHER CORROSIVE CHEMICALS WERE NOT USED FOR TESTING SYSTEMS OR STOPPING LEAKS? TESTS ® YES ❑ NO DRAIN READING OF GAG L TED NEAR WATER SUPPLY TEST RESIDUAL PRESSURE WITH VALVE IN TEST TEST CONNECTION: PSI CONNECTION OPEN WIDE 7,6 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 3 YES ❑ NO BLANK NUMBER USED LOCATIONS: NUMBER REMOVED TESTING 0 GASKETS WELDED PIPING ❑ YES ® NO IF YES... DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR -3? ® YES ❑ NO DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED IN WELDING COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR -3? ® YES CI NO DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A DOCUMENTED QUALITY CONTROL PROCEDURE TO INSURE THAT ALL DISCS ARE RETRIEVED, THAT OPENINGS IN PIPING ARE SMOOTH, THAT SLAG AND OTHER WELDING RESIDUE ARE REMOVED, AND THAT THE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED? ® YES . .❑ NO CUTOUTS DO YOU CERTIFY THAT YOU HAVE .A CONTROL FEATURE TO ENSURE THAT ALL (DISCS) CUTOUTS (DISCS) ARE RETRIEVED? ® YES ❑ NO HYDRAULIC NAME PLATE PROVIDED IF NO, EXPLAIN: DATA ® YES ❑ NO NAMEPLATE DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: REMARKS NAME OF SPRINKLER CONTRACTOR: JND FIRE SPRINKLER INC. TESTS WITNESSED BY FOICI=TY ER (SIGNED) TITL / DATE SIGNATURES � " - I .7 - 2 ^r "" i 1)`' '4f " I . — 9 •)-- FOR SPRINKLER CO TITLE DATE � R ( I r - DATE I L i ' /$ BU ki INSPEC SI ED) TITLE DATE ADDITIONAL EXPLANATION AND NOTES (BACK) •