Permit CITY OF TIGARD FIRE PROTECTION SYSTEM PERMIT ,14 COMMUNITY DEVELOPMENT Permit #: FPS2009 -00007
T f G A R j? 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 04/20/2009
•
Parcel: 1 S135BD00100
Jurisdiction: Tigard
Site address: 9600 SW OAK ST
Subdivision: Lot: 0
Project: Plaza West
Project Description: Upgrade and replace existing building's fire alarm system.
Owner: FEES
PLAZA WEST LLC Description Date Amount
BY NORRIS BEGGS & SIMPSON, 121 SW Permit Fee - COM 03/27/2009 $344.34
MORRISON ST STE 200 Tax - 12% State Surcharge 03/27/2009 • $41.32
PHONE: Plan Review - Fire Life Safety - COM 03/27/2009 $137.74
Contractor:
WESTERN STATES FIRE PROTECTION
13896 FIR ST STE B
OREGON CITY, OR 97045
PHONE: 503 - 657 -5155 -
FAX: 503- 657 -5182
•
Type of Use: COM
Class of Work: FPS Type of Const:
Occupancy Grp: B Height: ft
Stories: 5
Commercial Sprinkler System:
Sprinkler Required: Sprinkler Type:
Standpipe Required: Hazard:
Density: 0 Design Area: 0
K Factor: 0
•
Commercial Fire Alarm System:
Fire Alarm Required: Yes Alarm Type: Automatic
Pull Station Required: Yes Smoke Detectors Req: Yes
Battery Calcs Provided: Yes Cut Sheets Required: Yes
• Total $523.40
Valuations: Required Items and Reports (Conditions)
Sprinkler Valuation: 0
Residential Square Footage: 0
Fire Alarm Valuation: 46000
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applica . - -w. All wo . 'II be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
iss . - nce, or if work is susp- • ded for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Jtility Notification Center. T. ••-e es are set forth in OAR 952 - 001 -0010 through OAR 952 -001 -0100. You may obtain a copy of the rules
Issued By: Permittee Signature: •
Call 503.639.4175 by 7:00 a.m. for an Inspection that business.
This permit card shall be kept in a conspicuous place on the job site until completion of = project.
Approved plans are required on the job site at the time of each Inspection.
Pi_.a ly3T cfc,ex-). ccl oAte--- Sc—
EtiiUling Permit Application
Fire Protection System FOR OFFICE USE ONLY
City of Tigard RECEIVED Date/B ? ® 4/ Permit No.: 15 7
• 2 rI Plan Review
13125 SW Hall Blvd., Tigard, OR 97223 q � -11 II Phone: 503.639.4171 Fax: 503.598.196MQR I 2009 Date/B : i _Al Q /rte Other Permit:
T I G A R D Inspection Line: 503.639.4175 Date Ready : y: See Page 2 for
Internet: www.tigard- or.gov CITY OF TIGARD Notified/Method: Y ¢o t� / a A_i Supplemental Information
BUILDING DIVISInN , l . o - 1. ,( /14 E kt
TYPE OF WORK REQUIRED DATA: 1- AND 2- FAMILY DWELLING
❑ New construction ❑ Demolition Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
Addition/alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
❑ 1- and 2- family dwelling commercial /industrial
Valuation: $ 1
El Accessory building 12 Multi-family Number of bedrooms:
❑ Master builder ❑ Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: 96 00 d , LA) (17.1( New dwelling area: square feet
City/State /ZIP: O L� n 7 3 Garage /carport area: square feet
Suite/bldg. /apt. no.: Project / name: f,1 7.Al_ Lc �Es r Covered porch area: square feet
Cross street/directions to job site: S / � t � �, Deck area: square feet
l � Other structure area: square feet
REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: Lot no.: Permit fees* are based on the value of the work performed.
Tax map /parcel no.: Indicate the value (rounded to the nearest dollar) of all
equipment, materials, labor, overhead, and the profit for the
/ DESCRIPTION OF WORK work indicated on this application.
t G aLA-d � 4.,,ig 4,0 /#K -P�• PJC> S7,. N / j � 4.0 I ! di d / ( Valuation: $ ( ,� 1 000
/ f j - 44 7s- ? €44 Existing building area: � square feet
\ A J New building area: square feet
❑ PROPERTY OWNER ❑ TENANT Number of stories:
Name: Type of construction:
Address: Occupancy groups:
City/State /ZIP: Existing:
Phone: ( ) Fax: ( ) New:
❑ APPLICANT ❑ CONTACT PERSON NOTICE
Business name: All contractors and subcontractors are required to be
Contact name: licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: jurisdiction in which work is being performed. If the
City /State /ZIP: applicant is exempt from licensing, the following reasons
apply:
Phone: ( ) Fax:: ( )
E -mail:
CONTRACTOR BUILDING PERMIT FEES*
" � $ .f _ . ( / ( Pk as erefo Permit schedule)
fee:
Business name:
(iZ/CS7� ,pr ��di v! c„ � 7✓ Permit fee:
Address: /(3''9 /_ C- 4 .1 -h, O _ T ._.. ; -t it ' fe State surcharge (12% of permit fee):
City/State /ZIP: Q�tla(� 04 C i / 64 , 9 7• '1) FLS plan review (40% of permit fee):
Phone: S. 3) 6 S 7 _ _, 57-S--- / Fax: . (5 -- 63) 6 S' 7 _ S'- f' L (Due upon application.)
CCB lic.: / d ei ir7 V / 3 . ( vJ - _ t 1 i / Total permit fees:
Amount received: 523 ifQ
Authorized signature: -i`--
This permit application expires if a permit is not obtained
Print name: i b. / Dat-: ` . 2 p with 180 days after it has been accepted as complete.
_ ` --`• * Fee methodology set by Tri -County Building Industry
Service Board.
I:\Building\PermitstPS- PermitApp.doc 03 /23/06 440.4613T(11/02/COMIWEB)
City of Tigard: Fire Protection Permit Checklist •
Page 2 - Supplemental Information
Describe work to be done:
1.) ❑ New 2.) Modification to sprinkler heads only:
❑ Addition El 1 -10 heads: No plan review required.
❑ Alteration El 11+ heads: Plan review required.
❑ Repair
Number of sprinkler heads:
Additional description of work:
Type of System (Complete A, B, C or D as applicable):
A.) Commercial Sprinkler
❑ Wet El Dry
Additional Standpipes
Information: Hazard Group • •
Density
Design Area
_ K. Factor
Sprinkler Project Valuation: $
B.) Type I - Hood Fire Suppression System
Hood Project Valuation: I $
C.) Fire Alarm
Submittal shall Battery Calculations Zr Yes • ,
include: Individual Component 2r Yes
Cut Sheets N
Fire Alarm Project Valuation: $ (0 0
D.) Residential Sprinkler (Stand Alone System)
Square Footage: Permit Fee:
0 to 2,000 $187.50
2,001 to 3,600 $232.50
3,601 to 7,200 $292.50
7,201 and greater $381.50.
Sprinkler Project Square Footage: sq. ft.
Fire Protection Permit Fees
Project valuation subtotal (see A, B & C above): $
Permit fee based on project valuation (see fee schedule): $
Permit fee based on square footage (see D above): $
State Surcharge (12% of permit fee): $ .
FLS Plan Review (40% of permit fee): $
TOTAL: $
Plan review requires a completed application and 2 sets of plans' at submittal. Plan review fees are required at submittal.
1: \Building \Permits \FPS-PermitApp.doc 06 /25/08 2
rfi5 0:72757
FUNDAMENTALS OF FIRE ALARM SYSTEMS
FIRE ALARM SYSTEM
RECORD OF COMPLETION
72 -31
Name of protected props P /,~I-Z .4- (J4t=.rr
Address: 7G elA , f. 14) _ AA
Representative of protected property (name/phone):
Authority having jurisdiction: Ce A' d T, "5 _2
Address/telephonenumber. / I Z.� .S LU • �
• ...(f Q /ant:. T:g,....J I Oft. (4 6 3S - 7I
// r ,i. tion name / phone Representative name / phone
Installer i sh c.* is w.ees tet &ADS. - .J — it btu, t. L Je1.1 sal G.r7 -s rr
Supplier 4 D
Service organization - t• - /
Location of record (as- built) drawings: 4i" '.
Location of operation and maintenance manuals: 7 F • P
Location of test reports: dr F. A. P 7 p Fi..a_ l /ee /[ ee...
A contract for test and inspection in accordance with NFPA standard (s)
Contract No(s): ..4 00 I o Effective date: , ` am ? Expiration date: • x Po Jo
System Software —
(a) Operating system (executive) software revision level(s : 4 XL. 05 ✓u.d'tiiJ 9.09 a `� 4 ' d 0 07
(b) Site - specific software revision date: /8 v 140!.
(c) Revision completed by.
(name) (firm)
1. Type(s) of System or Service
NFPA 72, Chapter 6 -- Local
If alarm is transmitted to location(s) off premises, list where received:
NFPA 72, Chapter 8 -- Remote Station
Telephone numbers of the organization receiving alarm:
,vim, (800) Vet!) o - a (073
Supervisory:
Trouble:
If alarms are retransmitted to public fire service communications centers or others, indicate location and telephone
numbers of the organization receiving alarm
Indicate how alarm is rerrarsmiaed: r.i 7F.sl (Ls. Jet e4:.v.E 6;AI D Lit / Edo- IA) F•i• C• P. (n T)
NFPA 72, Chapter 8 -- Proprietary
Telephone numbers of the organization receiving alarm:
Alarm:
Supervisory:
Trouble:
If alarms are retransmitted to public fire service communications centers or others, indicate location and telephone
numbers of the organization receiving alarm:
Indicate how alarm Is retransmitted:
NFPA 72, Chapter 8 -- Central Station
Prune contractor. A ✓A NT C %A A O
Central station location: 'Pie re e..,.w to j 4 - .
FIGURE 4.5.2.1 Record of Completion. (NFPA 72, I of 4)
2002 Edition
re- created by fcoart
1 ;
NATIONAL FIRE ALARM CODE
72 -32
Means of transmission of signals from the protected premises to the central station:
McCulloh Multiplex One -way radio
V Digital alarm communicator Two-way radio Others
Means of transmission of alarms to the public fire service communications center.
(a)
(b)
System Location:
NFPA 72, Chapter 9 -- Auxiliary
Indicate type of connection: Local energy Shunt V Parallel telephone
Location of telephone number for receipt of signals: I LJM-, . —' .4 ✓ aA+Ty r &Arcd
2. Record of System Installation
(Fill out after installation is complete and wiring is checked for opens, shorts, ground faults, and improper branching
but prior to conducting operational acceptance tests.)
This system has beep installed in accordance with the NFPA standards as shown below, was inspected by
ji k, /Lt k io! .?/9 / GEi4- on J o ? ca 9 , includes the devices shown
in 5 and 6, and had been in service since
NFPA 72, Chapters 1 2 3 4 0 0 41,0 ® 9 10 11 (circle all that apply)
✓NFPA 70, National Electrical Code, Article 760
Manufacturer's instructions
Other (specify):
Si q
Signed: _..000.0. — Date: / 7 ,.,r . a u�
Organization: ct o
3. Record of System Operation 1,
Documentation in accordance with Inspection Testing Form, Figure 10.6.2.3, is attached .56" 4. + u III`'f - A v ( 7651'
All operational features and functions of this system were tested by Ai . #4 4..1,0 tI /9/ (.Ef ate
and found to be operating properly in accordance with the requirements of
_NFPA 72, Chapters 1 2 3 4 5 6 7 8 9 0 11 (circle all that apply)
NFPA 70, National Electrical Code, Article 760
Manufacturer's instructions
Other (specify): /
-�' ✓� Date: 9 .2e°
•
Organization: - - "Lc # . i .ml
4. Signaling Line Circuits
Quantity and c of signaling line circuits connected to system (see NFPA 72, Table 6.6.1):
Quantity: l Style: }' Class: g
FIGURE 4.5.2.1 Record of Completion. (NFPA 72.2of
2002 Edition
re- creased by fcoarl
FUNDAMENTALS OF FIRE ALARM SYSTEMS
72 -33
5. Alarm.Initiating Devices and Circuits
Quantity and class of initiating device circuits (see NFPA 72, Table 6.5) :
Quantity: / Style: Class j
MANUAL
(a) Manual stations /3 Noncoded Transmitters Coded Addressable r✓
(b) Combination manual fire alarm and guards tour coded stations As(A—
AUTOMATIC ll
Coverage: Complete Partial F/Its 17e.I + E,r. . L .s if t Jj
Selective Nonrequired
(a) Smoke detectors /.r Ion Photo ✓ Addressable . ✓
(b) Duct detectors Ion Photo Addressable
(c) Heat detectors FT _ RR FT/RR RC Addressable
(d) Sprinkler waterflow indicators: Transmitters _ _ Noncoded I Coded Addressable
(e) The alarm verification feature is disabled or enabled ✓ , changed from seconds to /p seconds.
(i) Other (list):
6. Supervisory Signal - Initiating Devices and Circuits (use blanks to indicate quantity of devices)
GUARD'S TOUR
(a) Coded stations
(b) Noncoded stations
(c) Compulsory guard's tour system comprised of transmitter stations and intermediate stations
Note: Combination devices are recorded under 5(b), Manual, and 6(a), Guard's Tour.
SPRINKLER SYSTEM
Check provided
(a) V Valve supervisory switches
(b) Building temperature points
(c) Site water temperature points
(d) Site water supply level points
Electric fire pump:
(e) Fire pump power
(f) Fire Pump running
(g) Phase reversal
Engine- driven fire pump:
(h) Selector in auto position
(i) Engine or control panel trouble
(j) Fire pump running
ENGINE - DRIVEN GENERATOR:
(a) Selector in auto position
(b) Control panel trouble
(c) Transfer switches
(d) Engine running
Other supervisory function(s) (specify):
FIGURE 4.5.2.1 Record of Completion. (NFPA 72, 3 of 4)
2002 Edition
ee_ A by f�narl
NATIONAL FIRE ALARM CODE
72 -34
7. Annunciator(s) f e.t.a.
N u m b e r . / T y p e : C t l u ' f t w L o c a t i o n : 4 i[ ij . �tib /��
8. Alarm Notification Appliances and Circuits
NFPA 72, Chapter 6 - Emergency Voice/Alarm Service
Quantity of voicefalarm channels: Single: Multiple:
Quantity of speakers installed: Quantity of speaker zones:
Quantity of telephones or telephone jacks included in system:
Quantity and the class of notification appliance circuits connected to system (see NFPA 72, Table 6.7):
Quantity: Style: Class:
Types and quantities of notification appliances installed:
(a) Bells With Visible
(b) Speakers With Visible
(c) Horns With Visible /Sf l
(d) Chimes With Visible
(e) Other. With Visible
(1) Visible appliances without audible: 9
9. System Power Supplies
(a) Fire Alarm Control Panel: 43K $820 XL-Nominal voltage: 1 .20 i/.}� 0 Current rating 2. S
Overcurrent protection: Type: 5 t C K T. Current rating •
ckt $� M Locatioa PAIL- 4ce--a -r .2" - E. 0-4. 444 /4 4.
(b) Secondary (standby):
Storage battery 4.i / - C `J( Amp -hour rating /8
Calculated capacity to drive system, in hours: t
Engine- driven generator dedicated to fire alarm system: .4)/4-
Location of fuel storage: (,...
(c) Emergency system used as backup to primary power supply: .v /A—
Emergency system described in NFPA 70, ArtIcle 700:
10. Comments
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 in . '""'�M er (title (date)
nix mg.
•
(signed) for ala 'r' (title) (date)
(signed) for central station (title) (date)
Upon completion of the system(s) satisfactory test(s) witnessed (if required by the authority having jurisdiction):
(signed) representative of the authority having jurisdiction (title) (date)
FIGURE 4.5.2.1 Record of Completion. (NFPA 72.4 of 4)
2002 Edition
re- created by fcoarl
Inspection Contract No. 4,4- DO / 0
File No.
FIRE PROTECTION SERVICES DIVISION
9` & Columbia Bldg. GH -51, Olympia, WA 98504 -4151
/ , , , FIRE ALARM SYSTEM REPORT OF INSPECTION
Date: ' ter . a. we., o�.O6 5
Name of Facility: 71,am:__, CJP.d'f'
Occupied as: • .,.... _..
Address: ((o GZ) S C U - �, 4 S c-e.e� City Ad-Fir.cli
County: _ Zip -! 7 2 Telephone
Building Designation (if more than one building)
dmg gn n ( ore >a g)
Inspection by: Mile Myhrvold Title: A & D Inspector
Date of inspection: t -4 pr-u 2-cre 9
-------------------------------- - - - - -- -------------------- - - ---- --- - T- ' + -
1. Type of Test: Monthly ❑ Quarterly ❑ Semi - Annual ❑ AnnualC .
2. Type of system: Non -coded Common coded ❑ Selective coded ❑ Dual coded ❑
(as pertaining to chapter 212 -14 WAC) • , '
3. Local Fire Department C - (1• P k-
4. Fire Department Official Contacted: .44—
5. Test Received at Fire Dep ant: YesNo ED - 6. ' Master Elm Reset /(J .� A.M. _ ,d ,4� P.M. '
7. Comments, explanation unsatisfactory results, actin taken, etc.
4 . • : • • .i r 14 0/ b -� i) 1E i . / i
f:eS. � " _ p�.+ l 1 z o� „l 6�e,,.. I 'F" , C) clad_
•
.)7X7 tom/ g dd d c JO,c I.v Q cr i s 7 6,01.
c
A %►`� g�on.d 69 - 3 045 0
8CR)— 6G0- ,x6
SFM 222, REV. 5/78
ORIGINAL FORM TO BE RETURNED TO STATE FIRE MARSHAL .
EQUIPMENT TESTED
SATISFACTORY
TYPE OF NUMBER OF TEST C1,•IECK
EQUIPMENT UNITS TESTED DATE , YES NO N/A TYPE AND MANUFACTURER
6 i • 2.-e5 XL-.
8. Control Panel f . -
9. Manual Station 3 6
I ,' I
10. Heat Detectors : / • '/
11. Smoke Detectors ? 0 � p,• V " i J p • P�.
12. Audible Alarm
Devices • 1,5 , �O / . V *5', �'G^1 r i
/ - `
13. Visual Alarm Devices 6 / ,, ✓ 5 . . -
14. Code Transmitters _
15. Automatic Door 7 ( �p�r / c e. / /ftJ
�J 1 ' I , V / �+� / a�swoL� • 16. Trouble Indicators - G 1 ' 4. 44-
17. Master Alarm Box / ✓ / /
18, Batteries /
��� ^ tJ
19. Cha , er a. ii !�! �� /7 ,� t -
�o fff
20. Generator I, •
21 Ventilation Control ( 6 Ik % a 1�T4.w C% L4-ftir? i
22. Fire Department
I _... , ection
23. Central Station
Interconnection i �� . (3 cc 4.71 - .d
Electric Alarm Bell Sprinkler C o f . „ a j' _ • � - 0 V
25. Sprinkler water Flow ' (o . V Tl
- / p - f1 c
Switch � 26. Sprinkler Gate Valve - - / / Vl ` V y
27. Annunciators / 4 P All , d -
. - _ .
28. Automatic Time Delay of General Alarm Minutes. None Installed D'G-
29. Test of alarm system on emergency power, satisfactory? Yes .+vu
30. This is to certify that this fire alarm system has been properly inspected for reliability covering the items listed in this
report and is consistent with NFPA Fire Alarm Maintenance Standards.
A. Signature of Owner or Representative:
B. Signature of Fire Alarm Firm Representative: ��, _
C. Name of Firm : Western States Fire Protection Co. O
D. Mailing Address: 13896 Fir Street. Suite B. Oregon City. OR 97045 Phone # (503057-5155
E. Electrical Contractors License # : CLE 108
F. Specialty Electrician License #: 51 1 ! - '6
•
Contractor's Material and Test Certificate for Aboveground piping
PROCEDURE
Upon completion of work Inspection and tests shall be made by the contractors representative and witnessed by an owners
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 owners representative's signature In no way prejudices any claim against contractor for faulty material, poor workmanship,
or failure to comply with approving authortys requirements or local ordinances.
PROPERTY NAME: Plaza West (DATE: G - 2 LI . O
PROPERTY ADDRESS: 9600 SW Oak Street, Tigard, Oregon 97223
ACCEPTED BY APPROVING AUTHORITIES (NAMES):
City of Tigard
ADDRESS:
13125 SW Hall Blvd., Tigard, Oregon 97223
PLANS INSTALLATION CONFORMS TO ACCEPTED PLANS LI YES U NO
EQUIPMENT USED IS APPROVED El YES ❑ NO
IF NO, EXPLAIN DEVIATIONS:
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION(] YES U 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: LI YES U NO
1. SYSTEM COMPONENTS INSTRUCTIONS El YES ❑ NO
2. CARE AND MAINTENANCE INSTRUCTIONS 0 YES ❑ NO
3. NFPA 25 17 YES ❑ NO
LOCATION SUPPLIES BUILDINGS:
OF SYSTEM 2nd Floor
YEAR OF ORIFICE TEMPERATURE
MAKE SIN MANUFACTURE SIZE QUANTITY RATING
Reliable R3615 2008 'b 139 155°F
Reliable R3625 2008 K 4 155°F
SPRINKLERS Reliable R4862 2008 17/32 2 155°F
•
PIPE AND Type of Pipe: 1" to 2" Black Schedule 40, 2'%" through 6" Black Schedule 10
FITTINGS Type of Fitting: Black Cast Iron Threaded 1" through 2", Victeulic Short Pattern Grooved Fittings
2'4 through 6" Diameter
ALARM MAXIMUM TIME TO OPERATE
VALVE ALARM DEVICE THROUGH TEST CONNECTION
OR FLOW TYPE MAKE MODEL MIN SEC
INDICATOR Paddle Potter VSR.F
DRY VALVE Q.O.D.
MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO.
TIME TO TRIP TIME WATER ALARM
THROUGH TEST WATER AIR TRIP POINT REACHED OPERATED
CONNECTION' PRESSURE PRESSURE AIR PRESSURE TEST OUTLET PROPERLY
DRY PIPE MIN SEC PSI PSI PSI MIN SEC YES NO
OPERATING Without
TEST Q.O.D.
Wtth
Q.O.D.
IF NO, EXPLAIN
'MEASURED FROM TIME INSPECTOR'S TEST CONNECTION IS OPENED
OPERATION
❑ PNEUMATIC ❑ ELECTRIC ❑ HYDRAULIC
PtPIAIQSUPERVISED LIVES U NO I DETECTING MEDIA SUPERVISED NO
DOES VAZVEQeERATE FROM THE MANUAL TRIP AND /OR REMOTE CONTROL STATIONS U YES U NO
DELUGE AND IS THERE AN ACC : FACILITY IN EACH CIRCUIT FOR TESTING •, EXPLAIN
PREACTION
VALVES ❑ YES • NO
DOES EACH CIRCU . - ••4 DOES EACH CIRCUIT MAXIMUM TIME TO
MAKE MODEL SUPERVISI • • • ALARM? - RATE VALVE RELEASE? OPERATE RELEASE
S NO NO MIN. SEC.
PRESSURE LOCATI MAKE & . SETTING STATIC PRESSURE RES • • - RESSURE FLOW RATE
REDUCIN OOR MODEL LOWIN 1......_
ST
INLET (PSI) OUTLET (PSI) INLET (PSI) OUTLET (PS OW (GPM)
.I
ROSTATIC rostatic tests shall be made at not less than 200 psi (13.6 bars) for two hours or 50 pal (3.4 bars) above
static pressu excess of 150 psi (10.2 bars) for two hours. Differential dry-pipe valve clappers shall be left open during
TEST nt damage. All abovegroung piping leakage shall be stopped.
DESCRIPTION PNEUMATIC: Establish 40 psi (2.7 bars) air pressure and measure drop which shall not exceed 1% psi (.01 bars) in 24 hours.
Test pressure tanks at normal water level and alr pressure and measure air pressure drop which shall not exceed
1% psi (0.1 bars) in 24 hours.
ALL PIPING HYDROSTATICALLY TESTED AT 200 PSI (BARS) FOR 2 HRS. IF NO, STATE REASON
DRY PIPING PNEUMATICALLY TESTED .r YES NO
EQUIPMENT OPERATES PROPERLY 20e PSI ® 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? MI YES ❑ NO
TEST TEST 'SUPPLY Y TEST CONNECTION: N�R J(I�A PSI (_BARS) I CONNECTION OPEN WIDE IN
PSI
UNDERGROUND MAINS AND LEAD IN CONECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE
' TO SPRINKLER PIPING.
VERIFIED BY COPY OF THE U FORM NO. 85B El YES ❑ NO I OTHER EXPLAIN
FLUSHED BY INSTALLER OF UNDER-
GROUND SPRINKLER PIPING MI YES ❑ NO
IF POWDER -DRIVEN FASTENERS ARE USED IN CONCRETE, HAS REP- I IF NO, EXPLAIN
RESENTATIVE SAMPLE TESTING BEEN SATISFACTORILY COMPLETED? 19 YES I NO
BLANK TESTING NUMBER USED 'LOCATIONS NUMBER REMOVED
GASKETS 0
WELDED PIPING LI YES U 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? El YES ❑ NO
DO YOU CERITIFY THAT THE WELDING WAS PREFORMED BY WELDERS QUALIFIED IN
WELDING COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR-3? MI YES ❑ NO
DO YOU CERITIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A
DOCUMENTED QUALITY CONTROL PROCEDURE TO ENSURE 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 YES ' ❑ NO
CUTOUTS DO YOU CERITIFY THE YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL
(DISCS) CUTOUTS (DISCS) ARE RETRIEVED? 0 YES I1 NO
HYDRAULIC NAME PLATE PROVIDED IF NO, EXPLAIN
DATA
NAMEPLATE fl YES ❑ NO
DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN:
REMARKS
. �� r / ' ,2- 2-o 01
NA Mt OF SNI CIN ' UN I KAG I
Wei em States Fire Protection Systems Company
TESTS WITNESSED BY
SIGNATURES FOR PRO) I / / , 0 ,,, E ' I � ( TITLE I DATE
FO - — R T• I E' • • •: � • '� NED) DA
I or> 144 aw I 6 •2.Y•09
ADDm • EXPLANATION AND N S i / - oi
•
•
Contractor's Material and 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 owners
representative. Ali 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: Plaza West (DATE: • O
PROPERTY ADDRESS: 9600 SW Oak Street, Tigard, Oregon 97223
ACCEPTED BY APPROVING AUTHORITIES (NAMES):
City of Tigard
ADDRESS:
13125 SW Hall Blvd., Tigard, Oregon 97223
PLANS INSTALLATION CONFORMS TO ACCEPTED PLANS IA YES U NO
EQUIPMENT USED IS APPROVED 0 YES ❑ NO
IF NO, EXPLAIN DEVIATIONS:
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATIONU YES U 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: LI YES U NO
1. SYSTEM COMPONENTS INSTRUCTIONS El YES ❑ NO
2. CARE AND MAINTENANCE INSTRUCTIONS 12 YES ❑ NO
3. NFPA 25 12 YES ❑ NO
LOCATION SUPPLIES BUILDINGS:
OF SYSTEM 3rd Floor
• YEAR OF ORIFICE TEMPERATURE
MAKE SIN MANUFACTURE SIZE QUANTITY RATING
Reliable R3615 2008 '/, 21 155°F
Reliable R3625 2008 Y, 3 155°F
SPRINKLERS Reliable R4862 2008 17132 2 155°F
PIPE AND Type of Pipe: 1' to 2' Black Schedule 40, 2e through 6' Black Schedule 10
FITTINGS Type of Fitting: Black Cast Iron Threaded 1' through 2', Vlctaulic Short Pattern Grooved Fittings
254' through 6' Diameter
MAXIMUM TIME TO OPERATE
LAFt ALARM DEVICE THROUGH TEST CONNECTION
VALVE
OR FLOW TYPE MAKE MODEL MIN SEC
INDICATOR Paddle Potter VSR.F
DRY VALVE Q.O.D.
MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO.
TIME TO TRIP TIME WATER ALARM
THROUGH TEST WATER AIR TRIP POINT REACHED OPERATED
CONNECTION' PRESSURE PRESSURE AIR 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 IS OPENED
•
•
\ OPERATION
❑ PNEUMATIC ❑ ELECTRIC ❑HYDRAULIC
SUPERVISED U YES U NO I DETECTING MEDIA SUPERVISED U NO -
DOES VA ERATE FROM THE MANUAL TRIP AND /OR REMOTE CONTROL STATIONS / YES U NO
DELUGE AND IS THERE AN ACCE : FACILITY IN EACH CIRCUIT FOR TESTING LAIN
PREACTION
VALVES ❑ YES I NO
DOES EACH CIRCU ••- -a DOES EACH CIRCUIT MAXIMUM TIME TO
MAKE MODEL SUPERVISI • • • ALARM? _ • RATE VALVE RELEASE? OPERATE RELEASE
- - S NO NO MIN. SEC.
PRESSURE - LOCATI • . & SETTING STATIC PRESSURE RESIDtf RESSURE FLOW RATE
REDUCIN OOR MODEL (FLOWIN
ST INLET (PSI) I OUTLET (PSI) INLET (PSI) I OUTLET (P OW (GPM)
• ROSTATIC: H . rostatic tests shall be made at not less than 200 psi (13.6 bats) for two hours or 50 pal (3.4 bars) above
static pressure In ' • s of 150 psi (10.2 bars) for two hours. Differential dry -pipe valve dappers shall be left open during
TEST test top _ - i e. All abovegroung piping leakage shall be stopped.
DESCRIPTION ■ 3•L • C: Establish 40 psi (2.7 bars) air pressure and measure drop which shall not exceed 134 psi (.01 bars) in 24 hours.
Test pressure tanks at normal water level and air pressure and measure air pressure drop which shall not exceed
1% psi (0.1 bars) In 24 hours.
ALL PIPING HYDROSTATICALLY TESTED AT 200 PSI (_BARS) FOR 2 HRS. IF NO, STATE REASON
DRY PIPING PNEUMATICALLY TESTED Ei YES NO
EQUIPMENT OPERATES PROPERLY El 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? p YES ❑ NO
DRAIN READING OF GAGE LOCATED NEAR TER. RESIDUAL PRESSURE WITH V yE IN TEST
TEST TEST SUPPLY TEST CONNECTION: g ` PSI (__BARS) CONNECTION OPEN WIDE PSI
UNDERGROUND MAINS AND LEAD IN CONECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE
I TO SPRINKLER PIPING.
VERIFIED BY COPY OF THE U FORM NO. 13513 In YES ❑ NO I OTHER EXPLAIN
FLUSHED BY INSTALLER OF UNDER-
GROUND SPRINKLER PIPING CI YES ❑ NO
IF POWDER -DRIVEN FASTENERS ARE USED IN CONCRETE, HAS REP- I IF NO, EXPLAIN
RESENTATNE SAMPLE TESTING BEEN SATISFACTORILY COMPLETED? 0 YES v NO
BLANK TESTING NUMBER USED (LOCATIONS (NUMBER REMOVED
GASKETS 0 l
WELDED PIPING LI YES U 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? El YES ❑ NO •
i DO YOU CERTTIFY THAT THE WELDING WAS PREFORMED BY WELDERS QUALIFIED IN
WELDING COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR-3? 0 YES ❑ NO
DO YOU CERTTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A
DOCUMENTED QUALITY CONTROL PROCEDURE TO ENSURE 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 YES ❑ NO
CUTOUTS DO YOU CERTTIFY THE YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL
(DISCS) CUTOUTS (DISCS) ARE RETRIEVED? 0 YES ❑ NO
HYDRAULIC NAME PLATE PROVIDED 'IF NO, EXPLAIN
DATA
NAMEPLATE ri YES ❑ NO
DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN:
REMARKS
e L
estem States Fire Protection Systems Company
/ v I TEST WITNESSED B
SIGNATURE - •'E' • E I NED) TITLE DATE
FO S INKLER COQ, OR (SIGNED TI DATE
./ 4...„..... 1! ;_ 1 ,L _. ill 6 -X1.0 • .
ADDITIO'• • /re LANATION AND NO
/lb •••■•••■•••
•
Contractor's Material and 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: Plaza West (DATE: j ` 2 - I 1' 07
PROPERTY ADDRESS: 9600 SW Oak Street, Tigard, Oregon 97223
ACCEPTED BY APPROVING AUTHORITIES (NAMES):
City of Tigard •
ADDRESS:
13125 SW Hall Blvd., Tigard, Oregon 97223
PLANS INSTALLATION CONFORMS TO ACCEPTED PLANS LJ YES U NO
EQUIPMENT USED IS APPROVED 12 YES ❑ NO
IF NO, EXPLAIN DEVIATIONS:
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATIONU YES U 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: LJ YES U NO
1. SYSTEM COMPONENTS INSTRUCTIONS 0 YES ❑ NO
2. CARE AND MAINTENANCE INSTRUCTIONS 0 YES ❑ NO
3. NFPA 25 12 YES ❑ NO
LOCATION SUPPLIES BUILDINGS:
OF SYSTEM 5th Floor
YEAR OF ORIFICE TEMPERATURE
MAKE SIN MANUFACTURE SIZE QUANTITY RATING
Reliable R3615 2008 '/a 41 155°F
Reliable R3625 2008 ¶4 3 155°F
SPRINKLERS Reliable R4862 2008 17132 2 155°F
•
PIPE AND Type of Pipe: 1" to 2" Black Schedule 40, 244• through 6" Black Schedule 10
• FITTINGS Type of Fitting: Black Cast Iron Threaded 1' through 2', Vkcaullc Short Pattern Grooved Fittings
244' through 6' Diameter
LM MAXIMUM TIME TO OPERATE
ALAR
AARM ALARM DEVICE THROUGH TEST CONNECTION
OR FLOW TYPE MAKE MODEL MIN SEC
INDICATOR Paddle Potter VSR-F
DRY VALVE Q.O.D.
MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO.
TIME TO TRIP TIME WATER ALARM
THROUGH TEST WATER AIR TRIP POINT REACHED OPERATED
CONNECTION' PRESSURE PRESSURE AIR 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 IS OPENED
•
\ OPERATION
❑ PNEUMATIC ❑ ELECTRIC ❑ HYDRAULIC
SUPERVISED YES • NO DETECTING MEDIA SUPERVISED Pi. In • NO
DOES VA ERATE FROM THE MANUAL TRIP AND /OR REMOTE CONTROL STATIONS YES LJ NO
DELUGE AND IS THERE AN ACC - FACILITY IN EACH CIRCUIT FOR TESTING • , .* - LAIN
PREACTION
VALVES ❑ YES • NO
DOES EACH CIRCUI • - -.4 DOES EACH CIRCUIT MAXIMUM TIME TO
MAKE MODEL SUPERVISI • , ALARM? - TE VALVE RELEASE? OPERATE RELEASE
—YES NO NO MIN. SEC.
PRESSURE LOCATI • , • KE 8. • SETTING STATIC PRESSURE RES RESSURE FLOW RATE
• REDUCIN OOR MODEL (FLOWN
•
•
• ST INLET (PSI) I 1 OUTLET (PSI) INLET (PSI) I OUTLET (PS OW (GPM)
HYDROSTATIC:. • rostatic tests shall be made at not less than 200 psi (13.6 bars) for two hours or 50 pal (3.4 bars) above
static pressu ; excess of 150 psi (10.2 bars) for two hours. Differential dry -pipe valve clappers shall be left open during
TEST to pre , ' damage. All abovegroung piping leakage shall be stopped.
DESCRIPTION PN • _ TIC: - 40 psi (2.7 bars) air pressure and measure drop which shall not exceed 1% psi (.01 bars) in 24 hours.
Test . i- ,- I : normal water level and air pressure and measure air pressure drop which shall not exceed
1% psi (0.1 bars) in 24 hours. .
ALL PIPING HYDROSTATICALLY TESTED AT 200 PSI LBARS) FOR _2 HRS. IF NO, STATE REASON
DRY PIPING PNEUMATICALLY TESTED El YES PEI NO
EQUIPMENT OPERATES PROPERLY tg YES U 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? El YES ❑ NO
DRAIN READING OF GAGE LOCATED NEAR WATER. RESIDUAL PRESSURE WITH VALVE IN TEST
TEST TEST !SUP TEST CONNECTION: '7 5 PSI (___,BARS) I CONNECTION OPEN WIDE Id PSI
UNDERGROUND MAINS AND LEAD IN CONECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE
TO SPRINKLER PIPING.
■ • VERIFIED BY COPY OF THE U FORM NO. 858 El YES ❑ NO I ' OTHER EXPLAIN
FLUSHED BY INSTALLER OF UNDER-
GROUND SPRINKLER PIPING El YES ❑ NO
IF POWDER -DRIVEN FASTENERS ARE USED IN CONCRETE, HAS REP- I IF NO, EXPLAIN
RESENTATIVE SAMPLE TESTING BEEN SATISFACTORILY COMPLETED? fi YES D NO
BLANK TESTING NUMBER USED !LOCATIONS ( NUMBER REMOVED •
GASKETS 0
WELDED PIPING EJ YES U NO I
IF YES...
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY
i WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR -3? 13 YES ❑ NO
I DO YOU CERITIFY THAT THE WELDING WAS PREFORMED BY WELDERS QUALIFIED IN
WELDING COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR-3? 0 YES ❑ NO
DO YOU CERITIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A
DOCUMENTED QUALITY CONTROL PROCEDURE TO ENSURE 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? O YES ❑ NO
CUTOUTS DO YOU CERITIFY THE YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL
(DISCS) CUTOUTS (DISCS) ARE RETRIEVED? 0 YES L1 NO
HYDRAULIC NAME PLATE PROVIDED IF NO, EXPLAIN
DATA
NAMEPLATE El YES ❑ NO
DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN:
REMARKS �-y1 {Q� 2
'
NAMt OF S LEIf L UN I KM, 1 -
estern States Fire Protection Systems Company
/ IESIb WITNESSED BY
SIGNATURES FOR P E iv •• r i . ED) TILE DATE
/ FO N ER CO ¶ • C ' R (SIGNED) Tm . DATE
�' 07 I
1rov I
ADDITIO j • ON AND NO S 444110
C-122 z
Contractor's Material and Test. Certificate for Aboveground piping
PROCEDURE
Upon completion of work Inspection and tests shall be made by the contractors representative and witnessed by an owner's
representative. All defects shall be corrected and system left in service before contractors 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 po 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: Plaza West - (DATE: �/ (' 07
PROPERTY ADDRESS: 9600 SW Oak Street, Tigard, Oregon 97223
ACCEPTED BY APPROVING AUTHORITIES (NAMES): •
City of Tigard
ADDRESS:
13125 SW Hall Blvd., Tigard, Oregon 97229
PLANS INSTALLATION CONFORMS TO ACCEPTED PLANS LI YES U NO
EQUIPMENT USED IS APPROVED El YES ❑ NO
IF NO, EXPLAIN DEVIATIONS:
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATIONUI YES U 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: LI YES U NO
1. SYSTEM COMPONENTS INSTRUCTIONS 0 YES ❑ NO
2. CARE AND MAINTENANCE INSTRUCTIONS 0 YES U NO
3. NFPA 25 12 YES ❑ NO
LOCATION SUPPLIES BUILDINGS:
OF SYSTEM Standpipe
YEAR OF ORIFICE TEMPERATURE
MAKE SIN MANUFACTURE SIZE QUANTITY RATING
SPRINKLERS
PIPE AND Type of Plpe: 1" to 2' Black Schedule 40, 21A- through 6" Black Schedule 10
FITTINGS Type of Fitting: Black Cast Iron Threaded V through 2', Vkxaulic Short Pattern Grooved Fittings
294' through 6' Diameter
ALARM MAXIMUM TIME TO OPERATE
VALVE ALARM DEVICE THROUGH TEST CONNECTION
OR FLOW TYPE MAKE MODEL MIN SEC
INDICATOR Paddle Potter VSR-F
DRY VALVE Q.O.D.
MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO. •
TIME TO TRIP TIME WATER ALARM
THROUGH TEST WATER AIR TRIP POINT REACHED OPERATED
CONNECTION' PRESSURE PRESSURE AIR 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 IS OPENED
•
OPERATION
❑ PNEUMATIC ❑ ELECTRIC ❑ HYDRAULIC /
TIPIAIQ,SUPERVISED U YES U NO I DETECTING MEDIA SUPERVISED U NO
DOES VAZOSOQERATE FROM THE MANUAL TRIP AND /OR REMOTE CONTROL STATIONS YES U NO
DELUGE AND IS THERE AN ACC - FACILITY IN EACH CIRCUIT FOR TESTING •, EXPLAIN
PREACTION
VALVES ❑ YES 11 NO
DOES EACH CIRCUI •.' - -4. DOES EACH CIRCUIT MAXIMUM TIME TO
MAKE MODEL SUPERVISI • • • S ALARM? ., - RATE VALVE RELEASE? OPERATE RELEASE
' S NO NO MIN. SEC.
PRESSURE LOCATI •,, • ICE ti • SETTING STATIC PRESSURE RES • • - RESSURE FLOW RATE
REDUCIN OOR MODEL FLOW'
ST _ INLET (PSI) OUTLET (PSI) INLET (PSI) OUTLET (PS OW (GPM)
HYDROSTATIC; • • rostatic tests shall be made at not less than 200 psi (13.6 bars) for two hours or 50 pal (3.4 bars) above
static pressu - „ _ — of 150 psi (10.2 bars) for two hours. Differential dry -pipe valve clappers shall be left open during •
TEST >.. - • : •ent damage. All abovegroung piping leakage shall be stopped.
DESCRIPTION PNEUMATIC: Establish 40 psi (2.7 bars) air pressure and measure drop which shall not exceed 1% psi (.01 bars) in 24 hours.
Test pressure tanks at normal water level and air pressure and measure air pressure drop which shall not exceed
1% psi (0.1 bars) in 24 hours.
ALL PIPING HYDROSTATICALLY TESTED AT 200 PSI LBARS) FOR 2 HRS. IF NO, STATE REASON
DRY PIPING PNEUMATICALLY TESTED El YES NO
EQUIPMENT OPERATES PROPERLY 0 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? 0 YES ❑ NO
DRAIN READING OF GAGE LOCATED NEAR WATER. RESIDUAL PRESSURE WITH VALVE IN TEST
TEST TEST SUPPLY TEST CONNECTION: PSI (-_BARS) I CONNECTION OPEN WIDE PSI
UNDERGROUND MAINS AND LEAD IN CONECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE
TO SPRINKLER PIPING.
VERIFIED BY COPY OF THE U FORM NO. (15I3 in YES ❑ NO I OTHER EXPLAIN
FLUSHED BY INSTALLER OF UNDER-
GROUND SPRINKLER PIPING El YES ❑ NO
IF POWDER -DRIVEN FASTENERS ARE USED IN CONCRETE, HAS REP- I IF NO, EXPLAIN
RESENTATIVE SAMPLE TESTING BEEN SATISFACTORILY COMPLETED? iSI YES 51 NO
BLANK TESTING NUMBER USED 'LOCATIONS NUMBER REMOVED
GASKETS 0
WELDED PIPING LJ YES U NO
IF YES...
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY i
WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR -3? El YES ❑ NO
DO YOU CERITIFY THAT THE WELDING WAS PREFORMED BY WELDERS QUALIFIED IN
WELDING COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR-3? 0 YES ❑ NO
DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A
DOCUMENTED QUALITY CONTROL PROCEDURE TO ENSURE 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 YES ❑ NO
CUTOUTS DO YOU CERTIFY THE YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL
(DISCS) - CUTOUTS (DISCS) ARE RETRIEVED? 0 YES n NO
HYDRAULIC NAME PLATE PROVIDED IIF NO, EXPLAIN
DATA
NAMEPLATE 0 YES ❑ NO
DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN:
REMARKS •
J z
NA riI 'UN I U T
estem States Fire Protection Stems Company
TESTS WITNEbbED B
SIGNATURES F • R PROPERTY OWNER (SIGNED) TITLE DATE
I - ' - • KLER CO 0 ED) , TITLE I DATE
• On • I Fec&iptalv I G' .2 q -ol
ADDITIONAON AND Nr.
C_..0 6 -04/ e.7
,„,......._ ii
•
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. . •