1600 SELVA MARINA DR - PIPING TEST S -
benderAmodlin
[-FIRE SPRINKLER.INC.
I/I Ali\ A
CONTRACTOR'S MATERIAL & 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 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
ATLANTIC BEACH COUNTRY CLUB -CABANA/FITNESS BLDG 9/15/14
PROPERTY ADDRESS
1600 SELVA MARINA DR. _
ACCEPTED BY APPROVING AUTHORITIES(NAMES)
City of Atlantic Beach
ADDRESS
PLANS YES ® NO ❑
INSTALLATION CONFORMS TO ACCEPTED PLANS
EQUIPMENT USED IS APPROVED
IF NO,EXPLAIN DEVIATIONS YES ® NO ❑
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION OF CONTROL VALVES AND YES 0 NO ❑
CARE AND MAINTENANCE OF THIS NEW EQUIPMENT.
IF NO,EXPLAIN.
INSTRUCTIONS
HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES: YES 0 NO 0
SYSTEM COMPONENTS INSTRUCTIONS YES 0 NO ❑
2.CARE AND MAINTENANCE INSTRUCTIONS YES 0 NO ❑
3.NFPA 25 YES 0 NO ❑
LOCATION SUPPLIES BUILDINGS
OF SYSTEMS Wet Pipe System
YEAR OF ORIFICE TEMPERATURE
MAKE MODEL MANUFACTURER SIZE QUANTITY RATING
TYCO TY3187 2014 1/2 14 200
TYCO TY3180 2014 1/2 22 200
SPRINKLERS _____ TYCO TY3235 2014 1 4 155
TYCO TY3531 2014 1/2 55 155
Tyco TY3138 2014 1/2 6 200
Tyco TY3190 2014 1/2 20 200
PIPE AND TYPE OF PIPE Sch 40&Sch 10
----_..__---------..---- -------------
FITTINGS TYPE OF FITTINGS Threaded & Grooved
— —�ALARM DEVICE MAXIMUM TIME TO OPERATE THROUGH TEST
CONNECTION
ALARM VALVE OR TYPE MAKE MODEL MIN. SEC.
FLOW INDICATOR Water Flow Device Potter VSR
r _ — — ...........— DRY VALVE
Q.O.D.
MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO.
TIME TO TRIP' WATER AIR TRIP POINT TIME WATER ALARM
THROUGH TEST PRESSURE PRESSURE AIR PRESSURE REACHED TEST OPERATED
CONNECTION OUTLER' PROPERLY
DRY PIPE MIN. SEC. PSI PSI PSI MIN. SEC. YES j NO
OPERATING WITHOUT
TEST Q.O.D. ❑ ❑
-WITH
Q.O.D. ❑ ❑
IF NO,EXPLAIN
'MEASURED FROM THE TIME INSPECTOR'S TEST CONNECTION IS OPENED
4
OPERATION ❑ PNEUMATIC ❑ ELECTRIC ❑ HYDRAULIC ❑
PIPING SUPERVISED YES ❑ NO ❑—1 DETECTING MEDIA SUPERVISED YES ❑ _ NO ❑
DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATIONS YES 0 NO ❑
IS THERE AN ACCESIBLE FACILITY IN EACH CIRCUIT FOR TESTING IF NO,EXPLAIN
DELUGE&
PREACTION YES ❑
VALVES NO ❑
DOES EACH CIRCUIT OPERATE DOES EACH CIRCUIT MAXIMUM TIME TO OPERATE
SUPERVISION LOSS ALARM OPERATE VALVE RELEASE RELEASE
_— MAKE MODEL YES NO YES NO MIN. 1 SEC.
❑ ❑ ❑ ❑
TEST 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 od 150 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 stopped.
DESCRIPTION PNEUMATIC:Establish 40 psi(2.7 bars)air pressure and measure drop which shall not exceed 1%pas(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% psi(0.1 bars)in 24 hours.
ALL PIPING HYDROSTAICALLY TESTED AT 200 PSI 2 HOURS IF NO,STATE REASON
FOR
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?
YES ® NO ❑
TESTS DRAIN READING OF GUAGE LOCATED NEAR WATER SUPPLY TEST PIPE: RESIDUAL PRESSURE WITH VALVE IN TEST PIPE OPEN WIDE
TEST STATIC PSI PSI
PRESSURE
Underground mains and lead in connections to system risers flushed before connection made to sprinkler piping.
VERIFIED BY COPY OF THE U FORM YES ❑ NO ❑ OTHER EXPLAIN
NO.85B
FLUSHED BY INSTALLER OF UNDER- YES ❑ NO 0
GROUND SPRINKLER PIPING
BLANK TESTING NUMBER USED LOCATIONS L NUMBER REMOVED
GASKETS 0
— — ._...-._._...._... WELDED PIPING YES 0 NO ❑ IF YES...-- ---- __---
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY WITH THE YES ® NO ❑
REQUIREMENTS OF AT LEAST AWS 010.9,LEVEL AR-3
WELDING DO YOU CERTIFY THAT WELDING WAS PERFORMED BY WELDERS QUALIFIED IN COMPLIANCE WITH THE YES 0 NO ❑
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 YES 0 NO ❑
PROCEDDURE 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
CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL CUTOUTS(DISKS)ARE YES 0 NO ❑
(RISKS) RETRIEVED
HYDRAULIC DATA NAMEPLATE PROVIDED I IF NO,EXPLAIN
NAMEPLATE YES 0 NO ❑ IL
DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN:
REMARKS •
NAME OF SPRINKLER CONTRACTOR
Bender& Modlin Fire Sprinklers, Inc. --
TESTS WITNESSED BY
FOR PROP:RTY'', -(SIGNED) TITLE
DATE
SIGNATURES \ ,`t\sk ^
FOR FIRE SPR( - c ' TOR(SIGNED) TITLE DATE
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ADDITIONAL EXPLANATIONS AND NOTES