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680 Mayport Rd MECH20-0013 4 CONTRACTOR'S MATERIAL & 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 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 NAMEDate L tC.aKrt `A-C.):'S� C sem*, IN -(Iii SC.._A-1-CC.A.__ 10 1 10 PROPERTY ADDRESS 6.1e0 MAY P`a, n c ACCEPTED BY APPROVING AUTHORITY('S)NAMES C IT-(,' 00 F I - r..i-t-I c, ei-rkc i-4- 4. -:� F Ri> ADDRESS PLANS INSTALLATION CONFORMS TO ACCEPTED PLANS ©(ES ❑ NO EQUIPMENT USED IS APPROVED AYES ❑ NO IF NO,EXPLAIN DEVIATIONS HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION Q.YES- ❑ 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: !/,, 1.SYSTEM COMPONENTS INSTRUCTIONS D-fa ❑ NO S 2.CARE AND MAINTENANCE INSTRUCTIONS L ❑ NO YE6 ❑ NO 3. NFPA 25 ❑ LOCATION SUPPLIES BUILDING: OF SYSTEM YEAR OF ORIFICE TEMPERATURE MAKE MODEL MANUFACTURE SIZE QUANTITY RATING I SPRINKLERS \/IKI r•ii� \ th 7307 tl Z �l L /S5` 0,g_ PIPE AND Type of Pipe: Schd.40 Lightwa FITTINGS Type of Fittings: Cast iron 125# and Grooved ✓` MAXIMUM TIME TO OPERATE ALARM DEVICE THRU TEST CONNECTION ALARM VALVE TYPE MAKE MODEL MIN. SEC. OR FLOW INDICATOR 111 Ktni(-, lit*11- CHG`S C DRY VALVE Q.O.D. MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO. TIME TO TRIP TRIP POINT TIME WATER ALARM IA WATER PRESSURE AIR PRESSURE AIRREACHEDOPERATED CONNECTION' PRESSURETEST OUTLET* PROPERLY PIPE MIN. SEC. PSI PSI PSI MIN. SEC. YES NO OPERATING Without ❑ ❑ TEST Q.O.D. With ❑ 0 Q.O.D. IF NO,EXPLAIN: 'MEASURED FROM TIME INSPECTOR'S TEST CONNECTION OPENED. (OVER) i OPERATION ❑ PNEUMATIC 0 ELECTRIC 0 HYDRAULIC PIPING SUPERVISED 0 YES 0 NO DETECTING MEDIA SUPERVISED ❑ YES 0 NO N ti DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATIONS 0 YES 0 NO \J/ IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT FOR TESTING IF NO,EXPLAIN /DELUGE& ❑YES 0 NO PREACTION VALVES DOES EACH CIRCUIT OPERATE DOES EACH CIRCUIT OPERATE MAXIMUM TIME TO MAKE MODEL SUPERVISION LOSS ALARM? VALVE RELEASE? OPERATE RELEASE YES NO YES NO MIN. SEC. 0 0 0 0 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 of 150 TEST 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 DESCRIPTION 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 PIPING HYDROSTATICALLY TESTED AT/200 ,PSI FOF(2/HRS. IF NO,STATE REASON: DRY PIPING PNEUMATICALLY TESTED 0 YES ❑ NO EQUIPMENT OPERATES PROPERLY 0 YES 0 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? TESTS ©-YES 0 NO DRAIN READING OF GAGE LOCATED NEAR WATER SUPPLY TEST RESIDUAL PRESSURE WITH VALVE IN TEST TEST CONNECTION: PSI CONNECTION OPEN WIDE PSI UNDERGROUND MAIN AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE TO SPRINKLER PIPING OTHER EXPLAIN VERIFIED BY COPY OF THE U FORM NO.85B 0 YES 0 NO FLUSHED BY INSTALLER OF UNDER- GROUND SPRINKLER PIPING ❑YES 0 NO BLANK NUMBER USED LOCATIONS: NUMBER REMOVED TESTING GASKETS WELDED PIPING g YES ❑ 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? EYES 0 NO DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED IN YES 0 NO COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.9,LEVEL AR-3? WELDING DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A DOCUMENTED QUALITY CONTROL PROCEDURE 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? fitl,YES 0 NO CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL (DISCS) CUTOUTS(DISCS)ARE RETRIEVED? A YES 0 NO HYDRAULIC NAME PLATE PROVIDED IF NO,EXPLAIN: DATAYES ❑ NO NAMEPLATE lEr DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: REMARKS NAME OF SPRINKLER CONTRACTOR: ni' /aN ij;i1 - S67}2,V1 Z— -- TESTS WITNESSED BY FOR PROPERTY OWNER(SIGNED) TITLE DATE SIGNATURES I I F ''INKLER CONT TOR . D) a ' I TITLE /C ' ' /" ,,'S„,_ I DATE -6 I I ADDITIONAL EXPLANATION AND NOTES (BACK) r CONTRACTOR'S MATERIAL & TEST CERTIFICATE FOR UNDERGROUND PIPING Procedure Upon completion of work,inspection and tests shall be made by 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 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 I DATE PROPERTY ADDRESS F c) MINS' Pea; leriiS ACCEPTED BY APPROVING AUTHORITY('S)NAMES (-111; LT:'lOAN-1'1C- t3(--r}c .f.- :1 P--6 ADDRESS PLANS INSTALLATION CONFORMS TO ACCEPTED PLANS 0 YES 0 NO EQUIPMENT USED IS APPROVED ''YES 0 NO IF NO,STATE DEVIATIONS: HAS THE PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION ❑"TES 0 NO OF CONTROL VALVES AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT. IF NO,EXPLAIN INSTRUCTIONS HAVE COPIES OF APPROPRIATE INSTRUCTIONS AND CARE AND MAINTENANCE CHARTS DYES ❑ NO BEEN LEFT ON THE PREMISES. IF NO,EXPLAIN SUPPLIES BLDGS. LOCATION f'&Ai / �'//e:///; PIPE TYPES AND CLASS (-, C TYPE JOINT ��/ PIPE CONFORMS TO , STANDARD 0-YES 0 NO UNDERGROUND FITTINGS CONFORM TOP,;-H/\ STANDARD 0-YES 0 NO PIPES IF NO,EXPLAIN AND JOINTS JOINTS NEEDING ANCHORAGE CLAMPED,STRAPPED,OR BLOCKED IN YES ❑ NO ACCORDANCE WITH /0_I)l}- STANDARD IF NO,EXPLAIN FLUSHING:Flow the required rate until water is clear as indicated by no collection of foreign material in burlap bags at outlets such as hydrants and blow-offs.Flush at flows not less than 400 gpm(15141/min)for 4-inch pipe,600 gpm(2271 I/min)for 5- inch pipe,900 gpm(2839 1/min)for 6-inch pipe, 1600 gpm(3785 I/min)for 8-inch pipe,2440 gpm(5678 I/min)for 10-inch pipe, and 3520 gpm(7570 I/min)for 12-inch pipe.When supply cannot produce stipulated flow rates,obtain maximum available. TEST HYDROSTATIC:Hydrostatic tests shall be made at not less than 200 psi(13.8 bars)for two hours or 50 psi(3.4 bars)above DESCRIPTION static pressure in excess of 150 psi.(10.3 bars)for two hours. LEAKAGE:New pipe laid with rubber gasketed joints shall,if the workmanship is satisfactory,have little or no leakage at the joints,The amount of leakage at the joints shall not exceed 2 qts per hr(1.89 I/h)per 100 joints irrespective of pipe diameter. The leakage shall be distributed over all joints.If such leakage occurs at a few joints the installation shall be considered unsatisfactory and necessary repairs made.The amount of allowable leakage specified above may be increased by 1 fl oz Per in.valve diameter per hour(30 mL/25 mm/h)for each metal seated valve isolating the test section.If dry barrel hydrants are tested with the main valve open,so the hydrants are under pressure,an additional 5 oz/min leakage is permitted for each hydrant. NEW UNDERGROUND PIPING FLUSHED ACCORDING TO N/'/%}STANDARD O-YES 0 NO BY:(COMPANY) //4/YE 4-72-44:4+/ y-//ZE SETS✓/C-L IF NO,EXPLAIN HOV�FL-USHING FLOW WAS OBTAINED THROUGH WHAT TYPE OPENING FLUSHING I P/UBLIC MAIN 0 TANK OR RESERVOIR ❑ FIRE PUMP 0 HYDRANT BUTT 1-iPEN PIPE TESTS , LEAD-INS FLUSHED ACCORDING TO /Vii-P6 STANDARD R-Y1=5❑ NO BY:(COMPANY) /4/114c)a-,iC•�}r f/f 5E/241 IF NO,EXPLAIN HOW FLUSHING FLOW WAS OBTAINED THROUGH WHAT TYPE OPENING Il LIC MAIN 0 TANK OR RESERVOIR 0 FIRE PUMP 0 Y CONN TO FLANGE&SPIGOT E PEN PIPE 114 HYDROSTATIC ALL NEW UNDERGROUND PIPING HYDROSTATICALLY TESTED AT TESTS 'Zt..e= PSI FOR HOURS TOTAL AMOUNT OF LEAKAGE MEASURED LEAKAGE GALS.OVER HOURS TEST ALLOWABLE LEAKAGE GALS.OVER HOURS NUMBER INSTALLED TYPE AND MAKE ALL OPERATE SATISFACTORILY HYDRANTS NC/V C ❑YES D NO WATER CONTROL VALVES LEFT WIDE OPEN ❑YES ❑NO CONTROL IF NO,STATE REASON VALVES HOSE THREADS OF FIRE DEPARTMENT CONNECTIONS AND HYDRANTS INTERCHANGEABLE WITH THOSE OF FIRE DEPARTMENT ANSWERING ALARM ❑YES ❑NO DATE LEFT IN SERVICE REMARKS NAME OF INSTALLING CONTRACTOR m c ' ,7n_v/ TESTS WITNESSED BY --- - /Z61, SIGNATURES FOR PROPERTY OWNER(SIGNED) TITLE DATE FbkISTAL NG CO RACTOR 1' ED) TITL • DATE ADDITIONAL EXPLANATIONS % NOTES //it r�j � ! /2--c ba / s� C -- ZC Record of Completion (� Name of protected property: S Address: YJ 5 0 M. pG r 4- c _ R Rep. of protected property(Name/Phfone): r,Z ;n C V r —-��. i� (0 U c79c- Authority Having Jurisdiction: R !� L� Address/telephone number: Cy 3 G - f-' Organization name/phone Representative name/phone Installer 5 Q-C-i ('e_ 0 i1�� }f- G-cx 1r ( a v J. Supplier Service organization kj - ( ( ( Location of record (as built)drawings: C) .� Location of owners manuals: /-1 ( Location of test reports: (� 1 A contract, dated , for test and inspection in accordance with NFPA standard(s) Contract No(s). Effective date: Effective date: System Software (a) Operating system (executive)software revision level(s): (b)Site-specific software revision level(s): (c) Revision completed by: (name) (firm) 1. Typ 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: Alarm: Supervisory: Trouble: If alarms are transmitted to public fire service communications center or others, indicate location and telephone number of the organization receiving alarm: NFPA 72, Chapter 8- Proprietary Telephone numbers of the organization receiving alarm: Alarm: Supervisory: Trouble: If alarms are transmitted to public fire service communications center or others, indicate location and telephone number of the organization receiving alarm: Indicate how alarm is retransmitted: Page 1 of 4 NFPA 72, Chapter 8-Central Station ee Prime contractor: ( t \ S Central station location: 1— G \A-) G cv .. Means of transmission of signals frorn-the protected premises to the central station: McCulloh Multiplex One-way radio 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 Parallel telephone Location of telephone number for receipt of signals: 2. Record of System Installation (Fill out after installation is complete and wiring checked for opens,shorts,ground faults,and improper branching,but prior to conducting operational acceptance tests.) This system has b en installed in accordance wit the NFPA standards as shown below, was inspected by -<— o /p)( C), includes the devices shown below, and has ben in service since a 7 / 8Of �`FPA 72, Chapters(j)2d46' 7)19 0 11 (circle all that apply) '\J /NFPA 70, National Electrical Code,Article 760 V Manufacturer's instructions Other(s ,ecify): 3 Signed: Date: Organization: i S L_C`_ u `C(' 3. Record of System Operation All operatic a fe `tures and functions of this system were tested by /V A (.� on r (f 0 , and found to be operating properly in accordance with the requirements of: NFPA 72, Chapter 70332110 11 (circle all that apply) "./ ,NFPA 70, National Electrical Code, Article 760 Manufacturer's Instruc' ns Other(tecify): Signed: �.- _�� __---- _. Date: ! (c5- Organization: f Se r_u 4. Signaling Line Circuits Quantity and class of signaling line circuits connected to system (see NFPA 72, Table 6.6.1) Quantity: Style: Class: Page 2 of 4 5. Alarm-Initiating Devices and Circuits Quantity and class of initiating device cir .iit (see NFPA 72, Table 6.5) Quantity: 8 Style: l Class: MANUAL -77 (a) Manual Stations Noncoded Transmitters ( Coded Addressable (b) Combination manual fire alarm and guard's tour coded stations AUTOMATIC Coverage: Complete Partial Selective Nonre9uired (a)Smoke detectors '7 Ion Photo , Li Addressable (b) Duct detectors Ion Photo /` Addressable (c) Heat detectors ' FT RR FT/RR v'' C Addressable (d)Sprinkler waterflow indicators: Transmitters Noncoded Coded Addressable (e)The alarm verification feature is disabled \Tor enabled , changed from seconds to seconds. (f)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 tour system comprised of transmitter stations and intermediate stations NOTE: Combination devices recorded under 5(b), Manual, and 6(a), Guard's Tour. SPRINKLER SYSTEM Check if ovided (a) ` Valve supervisory signaling attachments (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: (k) Selector in auto position (I) Control panel trouble (m) Transfer switches (n) Engine running Other Supervisory Function(s) (specify): Page 3 of 4 • 7. Annunciator(s) Number: I Type: i1 (i)Lcs. Location: 3 , O. (2,- 6 v \r- 8. 8. Alarm Notification Appliances and Circuits NFPA 72, Chapter 6 Emergency Voice/Alarm Service Quantity of voice/alarm channels: Single: Multiple: Quantity of speakers installed: Quantity of speaker zones: Quantity of telephones or telephone jacks included in system: Quantity and class of indicating appliance circuits connected to the system (see NFPA 72, Table 6.7): Quantity: Style: Class: Types and quantities of alarm indicating appliances installed: (a) Bells With Visible (b)Speakers With Visible (c) Horns aCj With Visible V"- (d) Chimes With Visible (e) Other: ` �,-�-f 0 h(p_,. With Visible 7-- (f) Visual appliances without audible: 9. System Power Supplies (a) Fire Alarm Control Unit: Nominal Voltage: ( . ..(7) Current Rating: Overcurrent Protection: Type: C 1(Nr Current Rating: O Location: yr or',(�P (b) Secondary (Standby): r A J a IA Storage battery: . ( k,,) Amp-hour rating Calculated capacity to drive system, in hours: Engine-driven generator dedicated to fire alarm system: Location of fuel storage: (c) Emergency system used as backup to primary power supply: 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: IQ f L / ;p (signed)for inst. a on contractor/supplier (title date) , J / a f ac (signdd or a/arm sery ce company (title (dat-) 1.1111111' ir0.4 (signedVor central station (title) (date) Upon completion of the system(s)satisfactory test(s)witnessed (if required by the Authority Having Jurigdiction : ,n " 1 DC7 signed "epresentative of t e PAitriority Having Jurisdiction (title) (date) tlV�ic•2�-� Reprinted with permission from NFPA 72,National Fire Alarm Code,Copyright°2002,National Fire Protection Association,Quincy,MA 02269.This reprinted material is not the complete and official position of the NFPA on the referenced subject which is represented only by the standard in its entirety. Distributed by: AFAA—P.O.Box 1569 Jasper, GA 30143 Web—www.afaa.org Phone—(678)454-3473 Fax—(678)454-3474 Page 4 of 4