HomeMy WebLinkAboutBLD2015-00058 - INSPECTION a
Contractor's Material and Test Certificate for A boveground 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 the 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 authorities
requirements or local ordinances.
Property Name Date
THE DINNING HALL @ CAMP PARSONS 06/25/2015
Property Address City State Zip
970 BEE MILL ROAD BRINNON WA
Accepted by approving authorities(names)
' JEFFERSON COUNTY
PLANS Address
Installation conforms to accepted plans isi Yes ❑ No
Equipment used is approved? 0 Yes ❑ No
If no,explain deviations
Has person in charge of fire equipment been instructed as to location of
control valves and care and maintenance of this new equipment? 0 Yes ❑ No
If no,explain
INSTRUCTIONS
Have copies of the following been left on the premises?
1. System Components Instructions 0 Yes ❑ No
2. Care and Maintenance Instructions n Yes ❑ No
r
3. NFPA 25 GI Yes ❑ No
LOCATION Supplies buildings MAIN DINNING HALL
OF SYSTEM
Make Model Year of Manufacture Orifice Size Quantity Temperature Rating
GLOBE GL5606 2015 1/2"/5.6 49 155
SPRINKLERS GLOBE GL5606 2015 1/2"/5.6 3 200
GLOBE GL5615 2015 1/2"15.6 92 155
GLOBE GL5615 2015 1/2"/5.6 109 200
TYCO DRY PEND/SW 2015 1"/5.6 15 155/286
Type of pipe
PIPE AND SCHED#10 GROOVED 2 1/2"AND LARGER/SCHED#40 1"THROUGH 2"THREADED
FITTINGS Type of fittings
D.I.GROOVED rll TINES 6 0 1.THREADED FITTINGS
ALARM ALARM DEVICES Maximum time to operate through test connection
VALVE Type Make Model Minutes Seconds
OR FLOW FLOW SWITCH POTTER VSR
INDICATOR
DRY VALVE Q.O.D.
Make Model Serial No. Make Model Serial No.
DRY PIPE N/A Time to trip through Water Pressure Air Pressure Trip Point Air Time water reached Alarm operated
OPERATING test connection'$ Pressure test outlet? properly
TEST Minutes Seconds psi psi psi Minutes Seconds Yes No
Without Q.O.D.
With Q.O.D. _
If no,explain
Operation ❑ Pneumatic ❑ Electric ❑ Hydraulic
Piping supervised ❑ Yes ❑ No I Detection media supervised ❑ Yes ❑ No
Does valve operate from the manual trip,remote,or both control stations? ❑ Yes ❑ No
DELUGE& Is there an accessible facility in each circuit If no,explain
PREACTION for testing? ❑ Yes ❑ No N/A
VALVES Does each circuit operate Does each circuit operate valve Maximum time to operate release?
Make Model supervision loss alarm? release?
Yes No Yes No Minutes Seconds
i
i2ESSURE Location&Floor Make&Model
RRE SUR ®- Setting
-� RESIDUAL PRESSURE(flowing) FLOW RATE
VALVE TEST ® ._ Outlet •
-_- Outlet Flow GPM
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
TEST excess of 150 psi(10.2 bars)for two hours. Differential Dry-Pipe Valve clappers shall be left open during test to prevent damage. All aboveground
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
II 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 pipe hydraulically tested at: 200 ,
psi(_�bar)for 2 hrs If no,state reason
Dry Pipe pneumatically tested
E•ui•mento.erates •ro•ed ❑ Yes No Yes 0 No
Do you certify as the sprinkler contractor that additives and additives chemicals,sodium silicate or derivatives of sodium silicate,brine,or other
corrosive chemicals were not used for testing systems or stopping leaks?
DRAIN Reading of gage located near ❑ Yes [h No
TEST water supply test connection: Residual pressure with valve
Underground mains and lead in connections to system risers pflushe b forebconnectiontmade to sprinkler piping
Verified by copy of the Contractor's Material&Test psi�_bar)
Certificate for Underground Piping. Yes ❑No
Flushed by installer of unde •round s•rinkler piping. 10 Other,explain
If powder driven fasteners are used in concrete,has representative Yes ❑No
sample testing been satisfactorily completed? ❑Yes ❑No If no,explain
BLANK TESTING Number used NIA
GASKETS 0 Locations
0
Number removed
Welded •i•in. yes 0
❑ No
Do you certify as the sprinkler contractor that welding procedures comply with the requirements of
WELDING at least AWS 82.1?
Do you certify that the welding was performed by welders qualified in compliance with the requirements
of at least AWS B2.1? 0 Yes ❑ No
Do you certify that the 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 a Yes ❑ No
residue are removed,and that the internal diameters of pi•n• are not •enetrated?
CUTOUTS Do you certify that you have a control feature to ensure that all cutouts(disks)are retrieved? El El Yes
DISCS ❑ No
HYDRAULIC Yes ❑ No
Nameplate provided?
DATA U Yes If no,explain
NAMEPLATE ❑ No
DATE left in service with all control valves open:
REMARKS
Name of sprinkler contractor
COLUMBIA FIRE INC.
Contractor's Address
111 SOUTH FINDLAY STREET City state
Signature SEATTLE Zip
- WA 98108
For p••perry owner(s.
Title Date
F.rspnnkler.••� .ctor(signed) Le.{,'Jttr...:L /c,,`F Ccn�: ..✓,lt�z i�C D
Title Z�`' �
Date
lditional explanation and notes
I certify that the information herein is true and that this sprinkler system was installed in accordance with
Chapter 6003, Texas Insurance Code and the rules and standards adopted by the State Fire Marshal's Office.
RME
Responsible Managing Employee(signature) BRUCE DOWNEY
:TIFICATION Responsible Managing Employee(print or type name)
BRUCE DOWNEY
RME License Number
COLUMFI952MG Date
06/25/2015
JEFFERSON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT
Fire Protection System Inspection Checklist:
Automatic Sprinkler System
NFPA 13,13R,13 D,15,24
General �► ��_�8
• Sprinkler System Permit No.: d��
. Building Permit No.:
. Facility Address: C4n+P P4 -f N$ DnV/MG /14LL
. Facility Name:
stem:
Wet ❑ Dry ❑Deluge ❑Preaction
Water Supply:
❑ Public *Private ❑Domestic ❑ Other Source:
Above-Ground Contractor's State License:
Inspector Int.&Dt.:�i
❑ Contractor's State License[Level 1 a:-❑ Certicate of Competency Stamp[Level]:
Underground Contractor's State License: Inspector Int.&DL:
❑ Contractor's State License[Level 1:
❑ Certicate of Competency Stamp[Level 1:
Pip Review
Inspector Int.&Dt.:L'I Plans Received[Date: 6•04//5*-]
le Hydraulic Calculations Summary Sheet
p/Detailed Work Sheet
1Y Graph Sheet •
Pr Back Flow Prevention Specification
13-"Public Water Works/Private System Review of Back Flow Prevention Device
❑ Above Ground Engineer's Stamp: Level and Expiration Date:
❑ Underground Engineer's Stamp: Level and Expiration Date:
Inspector Int.&Dt.: ach3,43 C,/
Site Inspection(Locates[
Sr Fire Department Connection[Storz]
-13.- Vault[s]
--a1-"Post Indicator Valve )it Inspector Int.&Dt.: � '
Underground Inspection[sl&System Testis] a�C i°
❑ Hydrostatic Test[2-hour,200 psi min. 13, 13R;Static @ 13D] - 3 a p J
• Start Time: hours @_#;End Time: hours @_# /it/ . -id F
❑ Pressurized Air Test[24-hour dry test to 40 psi]
• Start Time: hours @_#;End Time : hours @ #
❑ Flush with sieve and De-Chlorination tablet[to sewer man-hhole to psi flow reading
❑ Flow Test-Water Pressure Gauge Reading:
Ab9veground Inspectionlsl&System Testis]
Inspector Int.&DC DO/s
®' Hydrostatic Test[2-hour,200 psi min. 13, 13R;Static® 13D]
• Start Time:0,110 hours @ f/5- #;End Time://®D hours @ 2/4 # 215 5 /x 2/,sr
$ Pressurized Air Test[24-hour dry test to 40 psi] GP
-B—Flush with sieve and De-Chlorination tablet[to sewer man-hole only]
El Flow Test /
. Trip Pressure: ZO PSI @ 36 Seconds ] 3 6 Secs ����;/ /�
. Inspector's Water Motor Alarm[25 heads or more] [Tamper and flow
• Water Static : 7S PSI
. Water Residual: 10 PSI
14 Fire Alarm System Inter-tie with Sprinkler System Test
6 Approval for intermediate pipe cover[except @joints when prior to flow tests]d�fl
- FICIW K- 7106t�
JEFFERSON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT
Automatic Fire Alarm System Fire Protection System Inspection Checklist:
General
• Building Permit No.: #$ ^ OOD5B
. Facility Owner/Mgr.: .e ' ' 1'Go t-'7
. Facility Address: 994, ,eof�
- Facility Name: coApstP /.4ctoa j ,o,N/vC K-
. Facility Contact No.:
Sys em: ✓ _
le-Manual 0 Automatic ❑Voice Monitored ❑ Graphic ❑ Stand Alone
Elements:
Meat
/.3E' ( ❑ Rate of Rise j2it moke ❑Horn E(Hom/Strobe-C(Strobe
❑Coiling Door 12111anual Pulls ❑ Duct ❑Egress Control ❑ Damper ❑ Other:
Contractor's State License[&NICET]: Jam' ii i Inspector Int.&Dt1 @S/y/'r
Plan Review Inspector Int&DL:
❑ Plans Received[Date: ]
❑ Mfr.Specifications of individual elements
❑ Floor Plan(s)complete
❑ Battery Calculations,wring types and sizes.
❑ Power connection,Emergency Power Source
Site Inspection Inspector Int&Dt s/f/)
[7'System installation/location check-off
13r Panel Location
le Remote Annunciation
12r Access Keys
❑ Labeling
❑ Operating Instructions. 7 ire 4'C'4,TED
❑ Tools
System Test(s) / Inspector Int.&Dt.:6s///I(
a Heat ❑Rate of Rise O'Smoke C9 Horn lCl Hom/Strobe
❑ Egress Control Manual Pull-station ❑ Strobe
❑ Monitoring Agency Test ❑ Emergency Power Source
❑ Fire Alarm System Inter-tie with Sprinkler System Test(Tamper): 04 Secs.
Contractor's Material&Test Certificate: • Inspector Int.& D f /3'
As-Built Plans/Instructions in Plan Box(a FACP: Inspector Int.& Dt.:
Monitoring Aeencv
• Name: 0.4*s+2o p4 Jc A4/
• Address: V4,&, 9gGL awNA7P-s//`+'AC-S
. Contact Number: Z
- Account Number: p'
Panel Reset Code
• Code Number: / -- / — / /
Approval/Denial
• Inspector:
• Date: pA-7/5$7,e,-------
• Filed w/Bldg.Official:
(it Sprinkler head installation
® Piping,bracing,system installation
El Labeling[Control Valves,drains,etc.]
O Sprinkler Box Contents
O Data Plate on riser[completed data] 4 Crtem/6c-4;a7 M 41-,
® Fire Department Connection with caps
FDC Indentifier Escushions
etAdequate heat provision for piping protection �r F
Check Valves
lB Drain and drip device between FDC and Check Valve
a- Approval for Cover[except @joints when prior to flow tests]
�,f
Back Flow Prevention Approval:
Inspector Int.&Dt'�IL Sidi/34
°,
Underground Contractor's Material&Test Certificate Filed: Inspector Int.&Dt.:
Aboveground Contractor's Material&Test Certificate Filed: Inspector Int.&Dt.:
As-Built Plans/Instructions in Plan Box Inspector Int.&Dt.:
Water Service Purveyor
. Name:
• Address:
. Contact Number:
• Account Number:
Sprinkler Maintenance Company
. Name:
• Address:
. Contact Number: --
• Account Number:
Back Flow Prevention Device Maintenance Company
• Name:
. Address:
• Contact Number:
• Account Number:
Department Of Community Development Approval
• Inspector:
• Date Permit Signed:
• Filed w/Bldg.Official:
Notes :
A-4-0 ea- C'°A"--1 c7 N Od'rJ/e-
C t f-4 ✓44✓rX
.
Contractor's Material and Test Certificate for A boveground 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 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 the 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 authorities
requirements or local ordinances.
Property Name Date
THE DINNING HALL @ CAMP PARSONS 06/25/2015
Property Address City State Zip
970 BEE MILL ROAD BRINNON WA
Accepted by approving authorities(names)
JEFFERSON COUNTY
PLANS Address
Installation conforms to accepted plans 0 Yes ❑ No
Equipment used is approved? jp Yes ❑ No
If no,explain deviations
Has person in charge of fire equipment been instructed as to location of
control valves and care and maintenance of this new equipment? ri Yes ❑ No
If no,explain
INSTRUCTIONS
Have copies of the following been left on the premises? D Yes ❑ No
1. System Components Instructions
2. Care and Maintenance Instructions GI Yes ❑ No
3. NFPA 25 O Yes ❑ No
LOCATION Supplies buildings MAIN DINNING HALL
OF SYSTEM
Make Model Year of Manufacture Orifice Size Quantity Temperature Rating
GLOBE GL5606 2015 1/2"15.6 49 155
SPRINKLERS
GLOBE GL5606 2015 1/2"15.6 3 200
GLOBE GL5615 2015 1/2"/5.6 92 155
GLOBE GL5615 2015 1/2"/5.6 109 200
TYCO DRY PEND/SW 2015 1"/5.6 15 155/286
Type of pipe
PIPE AND SCHED#10 GROOVED 2 1/2"AND LARGER/SCHED#40 1"THROUGH 2"THREADED
FITTINGS Type of fittings
0.GROOVED FITTINGS&D.I.THREADED FITTINGS
ALARM ALARM DEVICES Maximum time to operate through test connection
VALVE Type Make Model Minutes Seconds
OR FLOW FLOW SWITCH POTTER VSR
INDICATOR
DRY VALVE Q.O.D.
Make Model Serial No. Make Model Serial No.
DRY PIPE Time to trip through Water Pressure Air Pressure Trip Point Air Time water reached Alarm operated
OPERATING NIA test connection''2 Pressure test outlet''2 properly
TEST Minutes Seconds psi psi psi Minutes Seconds Yes No
Without Q.O.D.
With Q.O.D.
If no,explain
Operation ❑ Pneumatic ❑ Electric ❑ Hydraulic
Piping supervised ❑ Yes ❑ No ' Detection media supervised ❑ Yes ❑ No
Does valve operate from the manual trip,remote,or both control stations? ❑ Yes ❑ No
DELUGE& Is there an accessible facility in each circuit If no,explain
PREACTION for testing? ❑ Yes ❑ No N/A
VALVES Does each circuit operate Does each circuit operate valve Maximum time to operate release?
Make Model supervision loss alarm? release?
Yes No Yes No Minutes Seconds
I.
,RAE .SURE Location&Floor Make& .el Setting STATIC PRESSURE RESIDUAL PRESSURE(flowing) FLOW RATE
REDUCING N/A Inlet(psi) Outlet(psi) Inlet(psi) Outlet(psi) Flow(GPM)
VALVE TEST N/A
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
TEST excess of 150 psi(10.2 bars)for two hours. Differential Dry-Pipe Valve clappers shall be left open during test to prevent damage. All aboveground
DESCRIPTION piping leakage shall be 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 pipe hydraulically tested at: 200 psi( bar)for 2 hrs If no,state reason
Dry Pipe pneumatically tested ❑ 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? O Yes ❑ No
TESTS DRAIN Reading of gage located near Residual pressure with valve
TEST water supply test connection: psi( bar) in test connection open wide, psi( bar)
Underground mains and lead in connections to system risers flushed before connection made to sprinkler piping
Verified by copy of the Contractor's Material&Test O Yes ❑No Other,explain
Certificate for Underground Piping.
Flushed by installer of underground sprinkler piping. IN Yes ❑No
If powder driven fasteners are used in concrete,has representative If no,explain
sample testing been satisfactorily completed? ❑Yes ❑No N/A
BLANK TESTING Number used Locations Number removed
GASKETS 0 0 0
Welded piping 0 Yes ❑ No
If yes...
Do you certify as the sprinkler contractor that welding procedures comply with the requirements of
WELDING at least AWS B2.1? a Yes ❑ No
Do you certify that the welding was performed by welders qualified in compliance with the requirements
of at least AWS 82.1? 0 Yes ❑ No
Do you certify that the 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? ri Yes ❑ No
CUTOUTS Do you certify that you have a control feature to ensure that all cutouts(disks)are retrieved? El Yes ❑ No
(DISCS)
HYDRAULIC Nameplate provided? If no,explain
DATA Fi Yes ❑ No
NAMEPLATE
DATE left in service with all control valves open;_
REMARKS
Name of sprinkler contractor
COLUMBIA FIRE INC.
Contractor's Address City State Zip
111 SOUTH FINDLAY STREET SEATTLE WA 98108
Signature Tests witnessed by
For p party owner(s ned The Date
F r sprinkler ctor(signed) Title Dat
Additional explanation and notes
/
I certify that the information herein is true and that this sprinkler system was installed in accordance with
Chapter 6003, Texas Insurance Code and the rules and standards adopted by the State Fire Marshal's Office.
RME BRUCE DOWNEY
Responsible Managing Employee(signature)
CERTIFICATION Responsible Managing Employee(print or type name)
BRUCE DOWNEY
RME License Number Date
COLUMFI952MG 06/25/2015
ccso` CMG
•
der' SH�NG'‘ JEFFERSON COUNTY
• DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street
Port Townsend, WA 98368
PROJECT #: bL/J
DESCRIPTION: CAW'/74.e401✓J(150/NOV6 WOLL /0//Td c,/3 '
c'//e/N/G c Ex s
DATE: d314.4/5y
REQUESTED BY: _S'Ql �' $
DATE:
APPROVED BY:
SERVICES COMPLETED BY: 779AfArt O +
DATE
CODE OFFICIAL REVIEW HOURS:,
NOTES: PcemPTAg2PP .P'D Ivor cv,vr)..v NPR Cvrdvesrs . S.E.
Gvv7-4e. ' Reewvrz, oa//ro
kt/ El
REPORT ATTACHED: YES NO
Bruce Downey
i PM f Designer
(206)232-8569 Work
(206)340-6100 Fax
� I. (42S)
628-3360 Cell
t_ bruaedgcoiumbiafire.net
U�11[J Fire S.Findlay St.
0\ Seattle,WA. woos
v.A.,m.columbiafre.net
7- ....3.,
LETTER OF TRANSMITTAL
Jefferson County
To Company: Community Development From: Bruce Downey
Attn: Sally L Ellis- Permit Technician Phone: 206-232-8569
Fax: 206-340-6100
621 Sheridan Street
Address: Port Townsend,WA 98368 Email: bruced @columbiafire.net
Phone: 360-379-4452 Date: 02/24/2015
Fax: Project: Camp Parsons
Email: sellis @co.jefferson.wea.us Columbia Job# 1406073
Re:
Copies Date Pages Description
1 06/25/2015 121 Material Submittal ( Electronic copy)
1 06/252015 2 Material Test Certificate (Above Ground )
❑ For approval ❑ Approved as submitted ❑ Resubmit copies for approval
® For your use ❑ Approved as noted ❑ Submit copies for distribution
® As requested ❑ Returned ❑ Return via Fax or Email
❑ For review and comment ❑ Returned for corrections ❑
REMARKS:
Elam Dooptay
Signed:
Printed Name: Bruce Downey Date: 06/25/2015
• k ooa S� •
Contractor's Material and Test Certificate for A boveground 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 autthokma�s owners oto arid
drthe contractor, It is understood the
owner's representative's signature in no way prejudices any claim against contractor for faulty material,poor
requirements or local ordinances.
Property Name 1 Date
0Date12015
THE DINNING HALL l CAMP PARSONS
Property Address I City City N I Zip
WA
State
970 BEE MILL ROAD
Accepted by approving authorities(names)
JEFFERSON COUNTY
PLANS Address
0 Yes ❑ No
Installation conforms to accepted plans 0 Yes ❑ No
Equipment used is approved?
If no,explain deviations
Has person in charge of fire equipment been instructed as to location of 0 Yes ❑ No
control valves and care and maintenance of this new equipment?
If no,explain
INSTRUCTIONS
Have copies of the following been left on the premises? p Yes No
1. System Components Instructions 0 Yes ❑ No
2. Care and Maintenance Instructions 0 Yes ❑ No
3. NFPA 25
LOCATION Supplies buildings MAIN DINNING HALL
OF SYSTEM
Make Model Year of Manufacture Orifice Size Quantity Temperature Rafing
GLOBE GL5606
2015 112'15.6 49 155
GLOBE GL5606
2015 1/2"15.6 3 200
SPRINKLERS
GLOBE GL5615 2015 1!2"l5.6 92 155
GLOBE GL5615
2015 1/2"/5.6 109 200
TYCO DRY PEND/SW
2015 1"15.6 15 155/286
Type of pipe
PIPE AND SCHED#10 GROOVED 2112'AND LARGER I SCHED#40 T THROUGH 2"THREADED
FITTINGS Type of fittings
D.I.GROOVED FITTINGS&D.I.THREADED FITTINGS
ALARM DEVICES Maximum time to operate through test connection
ALARM Model Minutes Seconds
VALVE Type Make I
OR FLOW
FLOW SWITCH I POTTER VSR
INDICATOR Q.O.D.
DRY VALVE Serial No.
Make
Model I Serial No. Make Model
DRY PIPE N/A Time to trip through Water Pressure Air Pressure Trip Point Air Time water reached Alarm operated
OPERATING
test connection" Pressure test outlet'z properly
TEST
Minutes Seconds psi psi psi Minutes Seconds Yes No
Without Q.O.D.
With Q.O.D.
If no,explain
Operation ❑ Pneumatic ❑ Electric ❑ Hydraulic Piping supervised ❑ Yes ❑ No I Detection media supervised ❑ Yes ❑ No
Does valve operate from the manual trip,remote,or both control stations?
❑ Yes ❑ No
DELUGE&
Is there an accessible facility in each circuit If no,explain
❑ ❑ No N/A
for testing? Yes
PREACTION Does each circuit operate valve Maximum time to operate release?
VALVES Does each circuit operate
Model supervision loss alarm? release?
Make I I
Yes No Yes No Minutes Seconds
• le
PRESSURE Location&Floor Make&Model Setting STATIC PRESSURE RESIDUAL PRESSURE(flowing) FLOW RATE
REDUCING N/A Inlet(psi) Outlet(psi) Inlet(psi) Outlet(psi) Flow(GPM)
VALVE TEST N/A
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
TEST excess of 150 psi(10.2 bars)for two hours. Differential Dry-Pipe Valve clappers shall be left open during test to prevent damage. All aboveground
DESCRIPTION piping leakage shall be 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 pipe hydraulically tested at: 200 psi(_bar)for 2 hrs If no,state reason
Dry Pipe 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? 1=1 Yes ❑ No
TESTS DRAIN Reading of gage located near Residual pressure with valve
TEST water supply test connection: psi( bar) in test connection open wide. psi( bar)
Underground mains and lead in connections to system risers flushed before connection made to sprinkler piping
Verified by copy of the Contractors Material&Test GI Yes ❑No I Other,explain
Certificate for Underground Piping.
Flushed by installer of underground sprinkler piping. ❑� Yes ❑No
If powder driven fasteners are used in concrete,has representative If no,explain
sample testing been satisfactorily completed? Oyes ❑No N/A
BLANK TESTING Number used Locations Number removed
GASKETS 0 0 0
Welded piping El Yes ❑ No
If yes...
Do you certify as the sprinkler contractor that welding procedures comply with the requirements of
at least AWS B2.1? ❑+ Yes ❑ No
WELDING Do you certify that the welding was performed by welders qualified in compliance with the requirements
of at least AWS 82.1? ❑� Yes ❑ No
Do you certify that the 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 that you have a control feature to ensure that all cutouts(disks)are retrieved? O Yes ❑ No
(DISCS)
HYDRAULIC Nameplate provided? If no,explain
DATA Il Yes ❑ No
NAMEPLATE
DATE left in service with all control valves open:_
REMARKS
Name of sprinkler contractor
COLUMBIA FIRE INC.
Contractor's Address City State Zip
111 SOUTH FINDLAY STREET SEATTLE WA 98108
Signature Tests witnessed by
For property owner(signed) Title Date
For sprinkler contractor(signed) Title Date
Additional explanation and notes
I certify that the information herein is true and that this sprinkler system was installed in accordance with
Chapter 6003, Texas Insurance Code and the rules and standards adopted by the State Fire Marshal's Office.
RME BRUCE DOWNEY
Responsible Managing Employee(signature)
Responsible Managing Employee(print or type name)
CERTIFICATION BRUCE DOWNEY
RME License Number Date
COLUMFI952MG 06/25/2015
, .61_0 ‘6- 0006'6 •
Contractor's Material and Test Certificate for A boveground 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 correctec
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 the 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 authorities
requirements or local ordinances.
Property Name Date
THE DINNING HALL @ CAMP PARSONS 06/25/2015
Properly Address City State Zip
970 BEE MILL ROAD BRINNON WA
Accepted by approving authorities(names)
JEFFERSON COUNTY
PLANS Address
Installation conforms to accepted plans p Yes D No
Equipment used is approved? El Yes E No
If no,explain deviations
Has person in charge of fire equipment been instructed as to location of
control valves and care and maintenance of this new equipment? 151 Yes ❑ No
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 0 Yes ❑ No
3. NFPA 25 GI Yes ❑ No
LOCATION Supplies buildings MAIN DINNING HALL
OF SYSTEM
Make Model Year of Manufacture Orifice Size Quantity Temperature Rating
GLOBE GL5606 2015 1/2'/5.6 49 155
SPRINKLERS GLOBE GL5606 2015 1/2'/5.6 3 200
GLOBE GL5615 2015 1/2/5.6 92 155
GLOBE GL5615 2015 1/T/5.6 109 200
-
TYCO DRY PEND/SW 2015 1'15.6 15 155/286
Type of pipe
PIPE AND SCHED#10 GROOVED 21/?AND LARGER/SCHED#401'THROUGH?THREADED
FITTINGS Type of fittings
DI.GROOVED FITTINGS A DI.THREADED FITTINGS
ALARM ALARM DEVICES Maximum time to operate through test connection
VALVE Type Make Model Minutes Seconds
OR FLOW FLOW SWITCH POTTER VSR
INDICATOR
DRY VALVE Q.O.D.
Make Model Serial No. Make Model Serial No.
DRY PIPE N/A Time to trip through Water Pressure Air Pressure Trip Point Air Time water reached Alarm operated
OPERATING test connection" Pressure test outlet''' properly '
TEST Minutes Seconds psi psi psi Minutes Seconds Yes No
Without Q.O.D.
With Q.O.D.
If no,explain
Operation ❑ Pneumatic ❑ Electric ❑ Hydraulic
Piping supervised ❑ Yes ❑ No Detection media supervised ❑ Yes ❑ No
Does valve operate from the manual trip,remote,or both control stations? ❑ Yes ❑ No
DELUGE& Is there an accessible facility in each circuit If no,explain
PREACTION for testing? ❑ Yes ❑ No N/A
VALVES Does each circuit operate Does each circuit operate valve Maximum time to operate release?
Make Model supervision loss alarm? release?
Yes No Yes No Minutes Seconds
T.. .,. . . , . . ... .. .. - — ._
: JEFFERSON EVELOPMENT LINTY DEPARTMENT OF COMMUNIT•
Fire Protection System Inspection Checklist
Au m
toatic Sprinkler System
NFPA 13,138,13 D,15,24
General, ��/�'ire
System Permit No.: J �
•. Building Permit No.:
• Facility Address: (,4AP oge.O.vS ONv/NG 4411–
. Facility Name:
S stem:
WWet ❑ Dry ❑Deluge ❑Preaction
Water Sunni
❑ Public *Private ❑Domestic ❑ Other Source:
Inspector Int. & Dt.
Above-Ground Contractor's State License:
❑ Contractor's State License[Level 1 t �.
❑ Certicate of Competency Stamp [Level__]:
Underground Contractor's State License: Inspector Int.& Dt.: __
❑ Contractor's State License[Level ]:
❑ Certicate of Competency Stamp[Level_I:
No Review
Inspector Int.& Dt.:
Plans Received[Date:,e. / 1/5',
le Hydraulic Calculations Summary Sheet
[YDetailed Work Sheet
Iii/Graph Sheet
IE Back Flow Prevention Specification
13---Public Water Works/Private System Review of Back Flow Prevention Device
❑ Above Ground Engineer's Stamp: Level and Expiration Date: —
❑ Underground Engineer's Stamp: Level and Expiration Date:
Inspector Int.& Dt.: CJS i3jti t 1i"
Site inspection ILocatesi
® Fire Department Connection[Storz]
.A.. Vault[s]
--GI/Post Indicator Valve I�RfL
Underground Inspection's]&System TegtIsl
Inspector Int &Dt DL: "1-V--11444
❑ Hydrostatic Test[2-hour,200 psi min. 13, 13R;Static @ 13D] 3 re r
• #
Start Time: hours @_#;End Time: hours @ //V Pit e
❑ Pressurized Air Test[24-hour dry test to 40 psi]
• Start Time: hours @_#;End Time: hours @__#
❑ Flush with sieve and De-Chlorination tablet[to sewer man�'ceonly] psi flow reading
❑ Flow Test–Water Pressure Gauge Reading: psi
A Inspector Int.&D( "A/f
�yveground Inspection's'& Testis' Static @ 13DJ
B- Hydrostatic Test[2-hour,200 psi min. 13, 13R; n
. Start Time:030 hours @ f/S #;End Time: /Loo hosts @ 2/S' # 215/��$ QL�/Z p�js�
$ Pressurized Air Test[24-hour dry test to 40 psi] op a
41--Flush with sieve and De-Chlorination tablet[to sewer man-hole only]
la Flow Test
• Trip Pressure:20 PSI @ 336 Seconds
. Inspector's Water Motor Alarm[25 heads or more] [Tamper and flow]: 36 Secs er OS-1/V /$
• Water Static : Z.$• PSI
. Water Residual: 10 PSI
(f' Fire Alarm System Inter-tie with Sprinkler System Test
t Approval for intermediate pipe cover[except joints when prior to flow tests]0�p
t MJ – '----
d
• •
(m prinkle h isaio
® S Piping,bracingr ead,nsystem tallt installation
Labeling[Control Valves,drains,etc.]
❑ Sprinkler Box Contents
❑ Data Plate on riser[completed data] 4, --ac/7- 7n HE!AL-
II Fire Department Connection with caps
• FDC Indentifier Escushions �t o fr po It
3 Adequate heat provision for piping protection -p
• Check Valves
® Drain Approval for Cover[except @joints when prior to tests]
� APP
Inspector Int.&Dt.
Back Flow Prevention Approval;
Under round Contr ctor's Materi 1&Test Certificate Filed:
Inspector Int.&Dt.:
Above ro nd Contractor's Material&Test Certificate Filed:
Inspector int.&Dt:
Inspector Int.&Dt.:
As-Built Plans/Instructions in Plan Box
Water Service Purveyor
• Name:
• Address:
. Contact Number:
• Account Number:
Sprinkler Maintenance Company
• Name: —
. Address:
• Contact Number:
• Account Number:
Bac Flow Prevention Device Maintenance Company
. Name:
• Address:
. Contact Number:
• Account Number:
Department Of Community Development Approval
• Inspector:
• Date Permit Signed:
• Filed w/Bldg.Official:
Notes:
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