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Home My WebLink About4700 LADY MOON DR - SPECIAL INSPECTIONS - 8/28/2017Contractor'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 the property owner or their authorized agent. All defects shall be corrected and system left in service before contractor's personnel finally leave the job. A certificate shall be filled our and singed 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 the contractor for faulty material, poor workmanship, or failure t comply with approving authority's requirements or local ordinances. Property Name: BANNER HEALTH Date: 8/10/2017 Property Address: 4700 LADY MOON DRIVE FORT COLLINS, COLORADO 80528 Accepted by approving Authorities (names) POUDRE FIRE AUTHORITY Address 102 REMINGTON STREET FORT COLLINS, CO 80524 Plans Installation conforms to accepted plans Q Yes No Equipment used is approved 121 Yes ❑ No If no, explain deviations Instructions Has person in charge of fire equipment been instructed as ❑ Yes ❑ No to location of control valves and care and maintenance of this new equipment? If no, explain leave copies of the following been left on the premises? 1. System components instructions Q Yes ❑ No 2. Care and maintenance instructions ❑✓ Yes ❑ No 3. NF-PA 25 FJI Yes ❑ No Location of Systems Supplies building: Year of Temperature Make Model/Sin Manufacture Orifice Size Quantity Rating Victualic UPR V2704 2017 1/2 55 200 Victualic PEND Al12 2017 1/2 99 200 Sprinklers Reli PEND RA1414 2017 1/2 36 155 Reli PEND R5418 2017 1/2 6 135 Reli PEND RA72t6 2017 3/4 21. 155 Fell PEND R4441 2017 3/4 6 135 Reli UPR RA1425 2017 L/2 8 200 Pipe and fittings Type of Pipe: Black Sch 10/Sch 40 Type of Fittings: Cast Iron Alarm Device Maximum time to operate through test connection Zone Make Model Minutes Seconds Alarm valve or flow Indicator ` Measured from time inspector's test connection is opened / Page 1 of 3 \ Q14n.9g-, Dry Valve R Q.O.D. - . Make Nlodel Serial No. Make Model Serial No. Dry pipe operating test Time to trip through test Water Pressure Air Pressure Trip point at air Time water reached Alarm operated connection" pressure test outlet* properly Minutes Sec. psi psi psi Minutes Sec. Yes No Without Q.O.D With Q.O.D If no explain: Operation: LJ Pneumatic U Electric U Hydraulic Piping supervised EFYes No Detecting media supervised Ll Yes No Does valve operate from the manual trip, remote, or both control stations? Is there an accessible facility in each circuit for testing? ❑ Yes No Deluge and If no, explain: preaction valves Does each circuit Does each circuit Maximum time to operate supervision Make Model loss alarm? operate valve release? operate release Yes No Yes No Minutes Sec. Location and Make and Model Setting Static Pressure Residual pressure (flowing) Plow rate Pressure reducing floor Inlet (psZpsi Inlet (psi) Outlet (psi) Flow (gpm) valve test I lVdrostatic: Hydrostatic tests shall be made at not less thar) For hours r SD psi (3.4 bar) above static pressure in excess of 150 psi (10.2 bar) for 2 hours.pe valve clappers shall be left open during the test to prevent damage. All aboveground leakage shall be stopped. Test description Pneumatic: Establish 40 psi (2.7 bar) air pressure and measure drop, which shall not exceed 1.5 psi (0.1 bar) in 24 hours. Test pressure tanks at normal water level and air pressure and measure air pressure drop, which shall not exceed 1.5 psi (0.1 bar) in 24 hours. All piping hydrostatically tested at: 200 psi for 2 hours f 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 silica�j , brine, or other corrosive chemicals were not used for testing systems or stopping leaks? W Yes ❑ No Tests Reading of gauge located near water supply test - Residual pressure with valve in test connection Drain test connection: p s-psi open wide: 11f psi Underground mains and lead-in connections to system risers flushed before connection made to sprinkler piping Verified by copy of he Contractor's Material and Test Other: Explain Certificate for Underground Piping. ❑ Yes ❑ No Flushed by installer of underground sprinkler piping ❑ Yes ❑ No If powder -driven fasteners are used in concrete, has If no, explain: representative sample testing been satisfactorily Blank testing Number used: Locations : Number removed: gaskets Page 2 of 3 016 7?91 Welding piping n Yes ❑ No If yes.......... Do you certify as the sprinkler contractor that welding procedures used complied with the [7] Yes ❑ No minimum requirements of AWS B2.1 ASME Section IX Welding and Brozing Quolijications, or other applicable qualification standard as required by the AEII? Do you certify that all welding was performed by welders or welding operators qualified E] Yes ❑ No in accordance with the minimum requirements of AWS B2.1, ASME Section IX Welding Welding and Brazing Qualifications, or other applicable qualification standard as required by the AHJ? Do you certify that the welding was conducted in compliance with a documented quality [2] Yes ❑ No control procedure to ensure that (1) all discs are retrieved; (2) that openings in piping are smooth, that slag and other welding residue are removed; (3) the internal diameters of piping are not penetrated; (4) completed welds are free from cracks, incomplete fusion, surface porosity greater than 1/16 in.: and (5) completed circumferential butt weld reinforcement does not exceed 3/32 in.? Cutouts (discs) Do you certify that you have a control feature to ensure that all cutouts (discs) ❑Yes ❑ No are retrieved? Hydraulic data Nameplate provided: IJ Yes ❑ No If no, explain: nameplate Remarks Date left in service with all control valves open: Name of sprinkler contractor Rapid Fire Protection, Inc. Test witnessed by _ Signatures r `�:�'^Y`� — S`i.[�t/r�ri.eAd2lw� T pr erty owner or their Title Date thor ed agent (signed) For sprinkler contractor (signed) Title Date Additional Explanations and note: Page 3 of 3