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OFFICE COPY
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
WOODS / -R e C
PROPERTY ADDRESS
f ° 51. /.S 10777 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: #3
OF SYSTEM
YEAR OF ORIFICE TEMPERATURE
MAKE MODEL MANUFACTURE SIZE QUANTITY RATING
GLOBE GL- 4710 2006 7/16" 67 155
GLOBE GL -DRY 2006 1/2' 20 155
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 MIN. SEC.
OR FLOW FLOW POTTER VSR -F 0 30 '
INDICATOR _
DRY VALVE Q.O.O.
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 O UTLET' PROPERLY
DRY PIPE MN. SEC. PSI PSI PSI MN. SEC. YES NO
OPERATING Without ❑ ❑
TEST Q.O.D.
With a ❑ ❑
Q.O.D.
IF NO, EXPLAIN:
'MEASURED FROM TIME INSPECTOR'S TEST CONNECTION OPENED. (OVER)
• OPERATION
U PNEUMATIC ❑ ELECTRIC ❑ HYDRAULIC
PIPING SUPERVISED ❑ YES ❑ NO DETECTING MEDIA SUPERVISED ❑ YES ❑ 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 &
PPEACTION ❑ 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 MN. 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 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 sto
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 -12 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 I READING OF GA LOCATED NEAR WATER SUPPLY TEST I RESIDUAL PRESSURE WITH VALVE IN TEST
TEST CONNECTION: 3 PSI CONNECTION OPEN WIDE 7/) PSI
UNDERGROUND MAIN AND IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE TO SPRINKLER PIPING
OTHER EXPLAIN
VERIFIED BY COPY OF THE U FORM NO. 85B ❑ YES CO 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 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 ❑ 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
NAMEPLATE CO YES ❑ NO
•
DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: 947.416
REMARKS
NAME OF SPRINKLER CONTRACTOR: JND FIRE SPRINKLER INC.
TESTS WITNESSED BY
FOR • • •'•ERN Elf D) TITLF� . ! 5 Lt � D v
SIGNATURES z"` �`]� 7
OR SP - INKLER CON T IGNE) j TITLE DAT
■ BU i i ( G INSPEC IGN -D) 1 TITLE DA.
ADDITIONAL EXPLANATION AND NOTES (BACK)