Report (75) Contractor's Material and Test Certificate for Aboveground g d Piping
PROCEDURE Z ,r 7Upon completion of work,inspection and tests shall be made by the contractor's representative and witnessedowner's epresseentative.
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: "rl 'c-.col _
PROPERTY ADDRESS: � �� � � ^� q
1
mit • L.)t
b ' ��: DATE: - -l - i
ACCEPTED BY APPROVING AUTHORITIES(NAMES)
PLANS
ADDRESS C
a.d
INSTALLATION CONFORMS TO ACCEPTED PLANS0 NO
�,(
EQUIPMENT USED IS APPROVED EYES
IF NO,EXPLAIN DEVIATIONS YES 0 NO
HAS PERSON IN CHARGE EUIPMENT BN
RUCTED AS
TO LOCATION OF CONTROL V LVES AND CARE AN MA
AND
174 YES 0 NO
IF NO,EXPLAIN
INSTRUCTIONS
HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES?
1.SYSTEM COMPONENTS INSTRUCTIONS
2.CARE AND MAINTENANCE INSTRUCTIONS N YES 0 NO
3.NFPA2S ' YES 0N
LOCATION SUPPLIES BUILDINGS S ❑NO
OF SYSTEM ♦,
MAKE YEAR OF ORIFICE
MODEL TEMPERATURE
MANUFACTURE SIZE QUANTITY
WARM] in][�i%F t�'� l RATING
SPRINKLERS [f�ig`��i�L w �'_��`
01
PIPE AND TYPE OF PIPE REEMEMEnommivC-..-V U'C Lt. 4-i0
V
FITTINGS TYPE OF FITTINGS . 1_ C �Z '
ALARM MAXIMUM TIME TO OPERATE
VALVE 14
.I:• . Y •►►I O.,
OR FLOW 11 .
INDICATOR a u•
MINDRY VALVE
MAKE MODEL SERIAL NO. MAKE Q.O.D.
MODEL SERIAL NO.
TIME TO TRIP
THROUGH TEST WATER AIR TIME WATER ALARM
DRY PIPETRIP POINT REACHED OPTED
OPERATING CONECTION PRESSURE PRESSURE AIR PRESSURE TEST OUTLET PROPERLY
TEST - MIN SEC PSI
WITHOUT PSI PSI MIN SEC`_=i Y;(S NO
EiMill
IF NO,EXPLAIN
DELUGE AND OPERATION 0 PNEUMATIC 0 ELECTRIC
0 HYDRALIC
PREACTION PIPING SUPERVISED 0 YES 0 NO DETECTING MEDIA SUPERVISED
VALVES ❑YES 0 NO
DOES VALVE OPERATE FROM THE MANUAL TRIP,REMOTE,OR BOTH
CONTROL STATIONS ❑ YES 0 NO
IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT IF NO,EXPLAIN
FOR TESTING 0 YES 0 NO
MAKE MODEL SUPER IOES CH CIRCUIT
I CUAOP OPERATE OES EACH CIRCUIT
MAXIMUM TIME TO
miiiiYESiiimmiiiiNO OPERATE VALVE RELEASE OPERATE RELEASE
NO YES MIN SEC
Page 1 of 2
LOCATION MAKE& SETTING STATIC PRESSURE RESIDUAL PRESSURE FLOW RATE -'
REDUCING PRESSURE
R &FLOOR Mo -LET(PSI) OUTLET(PSI) INLET(PSI) OUTLET(PSI) FLOW(GPM)
VALVE TEST
HYDROSTATIC: b drostatic tests shall be made at not less than 200 PSI(13.6 bars)for
2 hours
claporr50ssha11 PSI(3 e3.4 bars)
TEST •.1' • pressure in excess of 150 PSI(10.2 bars)for 2 hours. Differential dry-pipe valve
ft
DESCRIPTION open during the test to prevent damage. All aboveground leakage shall be stopped.
240
hours. pressure MAT Testt 4tanksat normall bars)
bars)
:Establish water level and air pre sure and measure air pressure drop,which shall
In
In
not exceed 1r PSI(0.1 bars)in 24 hours.ALL MING BARS FOR-a ___HRS IF NO,STATE REASON
Y TESTED
DRY PIPING PNEEUMATICALLYLTESTED AT 0 YES 0 NO
EQUIPMENT OPERATES PROPERLY 0
YES 0 NO
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT ADDITIVES AND CORROSIVE CHEMICALS,
SODIUM SILICATE OR DERIVITIVES OF SODIUM SILICATE,BRINE,OR OTHER CORROSIVE CHEMICALS
WER tfr OT USED FOR TESTING SYSTEMS OR STOPPING LEAKS?
ll YES 0 NO
RESIDUAL PRESSURE WITH�j 6'VE TEST IN
TESTS DRAIN READING OF GUAGE LOCATED NEAR WWATERRS) CONNECTION OPEN WIDE: PSI( BARS)
TEST SUPPLY TEST CONNECTION: 9P ( BA—
UNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE
CONNECTION MADE TO SPRINKLER PIPING
VERIFIED BY COPY OF THE U FORM NO.85B 0
YES 0 NO OTHER EXPLAIN
FLUSHED BY INSTALLER OF UNDER- 0 YES 0 NO
GROUND SPRINKLER PIPING
IF POWDER-DRIVEN FASTENERS ARE USED IN 0
YES 0 NO IF NO,EXPLAIN
CONCRETE,HAS REPRESENTATIVE SAMPLE
TESTING BEEN SATISFACTORILY COMPLETED? NUMBER REMOVED
BLANK TESTING NUMBER USED
LOCATIONS
GASKETS
WELDED PIPING .5 YES 0 NO
IF YES....
_ YES 0 NO
DO YOU CERTIFY AS THE
PROCEDURES COMPLY WITH THE REQUIREMENTS OF AT LEASTDING j�
AWS D10.9,LEVEL AR-3?
WELDING DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS
AYES 0 NO
QUALIFIED IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST
AWS D10.9,LEVEL AR-3?
DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE
WITH A DOCUMENTED QUALITY CONTROL PROCEDURE TO ENSURE 0 NO
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? 0 NO
CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO
(DISCS) ENSURE THAT ALL CUTOUTS(DISCS)ARE RETRIEVED?
IF NO,EXPLAIN
HYDRAULIC NAMEPLATE PROVIDED YES NO
DATA
NAMEPLATE
DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN
REMARKS c ,LI 7 G�\
NAME OF SPRINKLER CONTRAC I•
A-
k C'� V,�
,r �C
TEST DATE
WITNESSED
TNESSED FO 4' WNER(SIGNED) T p 14/
tt 4 /_, l
E DATE
• SPR r �► R C► OR S`GNED) - + l J-17
ADDITIONAL EXPLA P TIO f i lia
Page 2 of 2
Northwest.Fre Suppression, Inc.
FIRE ALARM/SUPPRESSION SYSTEM RECORD OF COMPLETION
Protected Premise: Owner's Rep &Phone:
Tigard Apartments Building 9
13327 Sw Hawks Beard St.
Tigard, Or. Permit# FPS2017-00074
This system was designed by,and equipment supplied by:
Northwest Fire Suppression,Inc., 1800 NW 169th Place Suite C#600
Beaverton,OR 97006 Phone: 503-644-7720 Fax: 503-644-8289
1. Types(s) of System or Service
Control Unit Manufacturer: Notifier Other
Model Number: NFW-100
Fire Alarm ❑
❑ ❑ Othe S-necify)
Type of Communication: 11 DAC with Cell E N/A
❑ Other(Specify)
Monitoring Provided By: Alarm Center Inc.
Account Number:
Alarm Code Style:
Phone Line 1 Number:
Phone Line 2 Number:
2. System Power Supplies
(a) Fire Alarm Control Panel:
Nominal Voltage: 120VAC Current Rating: 20 Amps
Breaker Location:
(b) Secondary (standby):
Sealed Lead Acid Batteries 8 AH Providing: 24 Hours Of Backup
3. System Software
Panel Firmware Rev#:
Application Software: PS-Tools
Rev Completed By: Name Company
Page 1 of 3
-7
4. Notification Devices
Quantity Device Type
1 Bells
Horns
Horn/Strobes
Strobes
Speakers
Annunciators
Other(Specify)
S. Initiating Devices
Quantity Device Type
1 Fire Alarm Pullstations
Suppression Manual Release Station
Ion Detectors
Photo Detectors
Duct Detectors I Type:
Heat Detectors
2 Waterflow Switches/Pressure Switches
Abort Switches
2 Tamper Switches
1 Low Air Switches
1 High Air Switches
Other(Specify)
6. Record of System Installation
This system has been installed in accordance with the National Electric Code, and
meets all requirements of Article 760 as a Power Limited Fire Alarm system.
After all device installation was complete (except control equipment final
terminations), all initiation, signal and control circuit wiring was tested and found to
be free of opens, shorts and ground faults.
The entire system was installed per the AHJ approved plans, and complete, accurate
"as built"notations have been provided to Northwest Fire Suppression, Inc.
Installing Contractor:
Responsible Journeyman: License#:
Signature: Date:
Page 2 of 3
7. Record of System Operation
All operational functions and features of this system were tested and found to be
working properly in accordance with the approved plans,per NFPA 70,National
Electric Code,Article 760,per NFPA 72, Chapters 1, 3, 4, 5, 6 and 7,and per the
manufacturer's instructions.
I have reviewed the"as built"drawings and find that they are accurate and complete.
Certifying Contractor: Northwest Fire Suppression Inc.
Responsible Journeyman: Kevin Hood License#:
Signature: 4751 LEA
Date:
k 61/4i117
8. Acceptance Testing Statements
Commissioning Technician:
I have tested and witnessed satisfactory performance of all system devices and control
functions, and/or have noted any exceptions on this Record of Completion.
Name: J�_v i t}o ejRepresenting: ► _ -
Signature: r�
/�� �� Date:
6721 17
Local Authority(or Authorities)Having Jurisdiction:
This system has -n inspected and is accepted for the jurisdiction I represent.
rm 1 1,n i
Name: Representing:
Signature: Date:
1. /L/% /0
9. Comments
Page 3 of 3