Report (41) Contractor's Material and Test Certificate for Aboveground� Piping
PROCEDURE F SZ o iC -nd i '7 Z
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: I ' y R(.' v.LS t ) C.1
PROPERTY ADDRESS: o- _ _ _ c CCC"{ DATE: q'-(Lt_. 7
ACCEPTED BY APPROVING AUTHORITIES(NAMES)C,j,,,�f. , 0-P- I.5C,rd
PLANS 1 1 _3
ADDRESS
INSTALLATION CONFORMS TO ACCEPTED PLANS al YES 0 NO
EQUIPMENT USED IS APPROVED AYES 0 NO
IF NO,EXPLAIN DEVIATIONS
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS Az YES 0 NO
TO LOCATION OF CONTROL VALVES AND CARE AND MAINTENANCE
IF NO,EXPLAIN
INSTRUCTIONS
HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES?
1.SYSTEM COMPONENTS INSTRUCTIONS ,r. YES 0 NO
2.CARE AND MAINTENANCE INSTRUCTIONS YES ❑NO
3.NFPA 25 OYES ❑NO
LOCATION SUPPLIES BUILDINGS N
1
OF SYSTEM
YEAR OF ORIFICE TEMPERATURE
MAKE MODEL MANUFACTURE SIZE QUANTITY RATING
..._`,OA link;Li 'D ' I" ylf3 0.a-. C a
SPRINKLERS Li,(A-0,10:- V IP)CJ ` -(.` frj %1/4‘`" —4, 7 C C
-1"yc)e TN/d43) ')-o a-1 2- 111c.
.)U. 1ti C, W 71 0 "o 17 I 'h._ 3'3r... 1 ce'
PIPE AND TYPE OF PIPE C-9 'i. C- .1 (\' k L
FITTINGS TYPE OF FITTINGS C•9..I,C 1 C�r' i (r-Ca e.� Dlil
MAXIMUM TIME TO OPERATE
ALARM ALARM DEVICE. THROUGH TEST CONNECTION
VALVE
OR FLOW TYPE MAKE. MODE!. MIN SEC
INDICATORa 2
Flt 5yS Stv,Sc. J
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
DRY PIPE CONECTION PRESSURE PRESSURE AIR PRESSURE TEST OUTLET PROPERLY
OPERATING MIN SEC PSI PSI PSI MIN SEC YES NO
TEST WITHOUT �y t Z Q ' 11_� 7 0 C,,' 1 J�
O.O.D. , ' t..) D t IG �.J
WITH
Q.O.D.
IF NO,EXPLAIN
OPERATION 0 PNEUMATIC 0 ELECTRIC 0 HYDRALIC
DELUGE AND
PREACTION PIPING SUPERVISED ❑ YES 0 NO DETECTING MEDIA SUPERVISED 0 YES 0 NO
VALVES
DOES VALVE OPERATE FROM THE MANUAL TRIP,REMOTE,OR BOTH 0 YES 0 NO
CONTROL STATIONS
IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT IF NO,EXPLAIN
FOR TESTING 0 YES 0 NO
DOES EACH CIRCUIT OPERATE DOES EACH CIRCUIT MAXIMUM TIME TO
MAKE MODEL SUPERVISION LOSS ALARM? OPERATE VALVE RELEASE OPERATE RELEASE
YES NO YES NO MIN SEC
Page 1 of 2
_ 4
LOCATION MAKE& SETTING STATIC PRESSURE RESIDUAL PRESSURE FLOW RATE ,
PRESSURE &FLOOR MODEL (FLOWING)
REDUCING LET(PSI) OUTLET(PSI) INLET(PSI) OUTLET(PSI) FLOW(GPM)
VALVE TEST
HYDROSTATIC:Hy.,ostatic tests shall be made at not less than 200 PSI(13.6 bars)for 2 hours or 50 PSI(3.4 bars)
TEST .-- - . ' . - excess of 150 PSI(10.2 bars)for 2 hours. Differential dry-pipe valve clappers shall be left
DESCRIPTION open during the test to prevent damage. All aboveground leakage shall be stopped.
PNEUMATIC:Establish 40 PSI(2.7 bars)air pressure and measure drop,which shall not exceed 1' 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 Ph PSI(0.1 bars)in 24 hours.
ALL PIPING HYDROSTATICALLY TESTED AT. `' SI BARS FOR HRS IF NO,STATE REASON
DRY PIPING PNEUMATICALLY TESTED 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
WE OT USED FOR TESTING SYSTEMS OR STOPPING LEAKS?
YES 0 NO
TESTS DRAIN READING OF GUAGE LOCATEUVEAR WATER RESIDUAL PRESSURE WIT1L .?LVE TEST IN
TEST SUPPLY TEST CONNECTION:-D*PSI ( BARS) CONNECTION OPEN WIDE: rDPSI( BARS)
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 [g`,,YES 0 NO OTHER EXPLAIN
FLUSHED BY INSTALLER OF UNDER-
GROUND SPRINKLER PIPING A YES 0 NO
IF POWDER-DRIVEN FASTENERS ARE USED IN RYES 0 NO IF NO,EXPLAIN
CONCRETE,HAS REPRESENTATIVE SAMPLE
TESTING BEEN SATISFACTORILY COMPLETED?
BLANK TESTING NUMBER USED I LOCATIONS NUMBER REMOVED
GASKETS
WELDED PIPING YES 0 NO
IF YES....
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING 'G YES 0 NO
PROCEDURES COMPLY WITH THE REQUIREMENTS OF AT LEAST
AWS D10.9,LEVEL AR-3?
WELDING DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS JR.YES 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
THAT ALL DISCS ARE RETRIEVED,THAT OPENINGS IN PIPING ARE 'YES 0 NO
SMOOTH,THAT SLAG AND OTHER WELDING RESIDUE ARE REMOVED,
AND THAT THE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED?
CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO Cit YES 0 NO
(DISCS) ENSURE THAT ALL CUTOUTS(DISCS)ARE RETRIEVED?
HYDRAULIC NAMEPLATE PROVIDED IF NO,EXPLAIN
DATA p YES 0 NO
NAMEPLATE
DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN
REMARKS
NAME OF SPRINKLER CONTRACTOR
TEST k- i s)(t .� C?71
WITNESSED FOR PROPERTY OWNER(SIGNED) TITLE DATE
BY
F S' I *TRACTOR(SIGNED) TITLE DATE
0 tr -,e. ,.Y.N, ? - /t-/- /7
ADDITIONAL LANATIO • I OTES
NIlk
Page 2 of 2
Northwest Fire Suppression, Inca
FIRE ALARM/SUPPRESSION SYSTEM RECORD OF COMPLETION
Protected Premise: I Owner's Rep&Phone:
Tigard Apartments Building 10
13225 Sw Hawks Beard St.
Tigard, Or. Permit# FPS2017-00075
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 I Other
Model Number: NFW-100
® I Fire Alarm El
Other Evcify)
Type of Communication: ® I DAC with Cell { C 1 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:
NBreakerominalLocation:Voltage: 1 120VAC 1 Current Rating: 120 Amps I
I
(b) Secondary(standby):
I Sealed Lead Acid Batteries 18 All I Providing: 1 24 Hours Of Backup
3.System Software
Panel Firmware Rev#:
Application Software: PS-Tools
Rev Completed By: Name I Company
Page 1 of 3
4.Notification Devices
Quantity Device Type
1 Bells
Horns
Horn/Strobes
Strobes
Speakers
Annunciators
Other(Specify)
5.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