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CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
Date Rec' d
II 5. 0(,
I. White File
2. Pinlc City
] Yellow Applica..
h~G //1/ ()0. 0064-
I PERMIT NO. &? I 0 f3 2- I
/38/0 .sH6.PfI~~ PAm
I ZONING '--l I
LEGAL DESCRIPTION (office use only)
LOT
BLOCK
ADDITION
PID
OWNER
OName) Shepherd Path Sr. Housing
(Address) 13760 McKenna Road NW, Prior Lake, MN
(Phone)
BUll..DER
(Company Name) Total Fire Protection, Inc.
(Contact Name) Val Mester
(Address) 1
(Phone) 605-582-2400
(Phone) 605-582-2400
TYPE OF WORK m New Construction ODeck o Porch o Re.Roofing ORe-Siding OLower Level Fimsh 0 Fireplace
OAddition OAlteration OUtility Connection 0 Misc.
CODE: OJ.R.C. OLB.C.
Type of Construction:
Occupancy Group: g B
Division:
IT
IV GJCAJ B
I M R S U
3 4 S
PROJECT COST/VALUE S
(excluding land)
400,000.00
is application which is to the bnt of my knowledge true and correct. I also certifY that I am the owner or authonzcd agent for the
' I conform to aU existing state and local Jaws and will proc<<d in accordance with submined plans, I am aware that the building
ore. I hereby agrtt that the dry official or a designee may enter upon the pr<>perty to perform needed IDspcctions,
".-
x
C050
Contractor's License No.
Permit Valuation
Permit Fee
Park Support Fee
SAC
#
#
$
S
S
S
$
S
S
S
#
#
Plan Check Fee
State Surcharge
Penalty
Plumbing Permit Fee
Mechanical Permit Fee
Sewer & Water Permit Fee
Gas Fireplace Permit Fee
Water Meter Size 5/S"; I";
Pressure Reducer
Sewer/Water Connection Fee
Water Tower Fee
Builder's Deposit
Other
TOTAL DUE
11-1-05
Date
$
$
$
$
$
S
$
S
S
5 Your Buildlnll Permit When Approved
/
(",
ThIS IS to certifY that the request in the above application and accompanying documents is in accordance with the Ciry Zoning dinance and may proceed as requl'Sted, This document
when signed by the Ciry Planner constitutes a temporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Cl-rtirlcatc of Occupancy must be
issued
Planning Director
Date Special Conditions. if an
24 hour notice for all Inspections (9~21447-98!1O, fax (952) 447-424~
16200 Eagle Creek Avenue Prior Lake, MN 55372
[I]
CONTRACTOR'S MATERIAL & TEST CERTIFICATE
PARTS A & C - SPRINKLER 81 WATER SPRAY ABOVEGROUND PIPING (Fill Out Separate Certificate For Each Riser!
PROCEDURE
UPON COMPl.ETlON OF WORK, INSPECTION AND TESTS SHAl.l. 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 MEN
FINALLY l.EAVE THE JOB.
A CERTIFICATE SHAl.l. BE FIl.l.ED OUT AND SIGNED BY BOTH REPRESENTATIVES. COPIES SHAl.l. BE PREPARED FOR APPROVING
AUTHORITIES, OWNERS AND CONTRACTOR. IT IS UNOERSTOOD THE OWNER'S REPRESENTATIVE'S SIGNATURE IN NO WAY PREJ-
UDICES ANY Cl.AIM AGAINST CONTRACTOR FOR FAUl.TY MATERIAl., POOP WORKMANSHIP, OR FAIl.URE TO COMPLY WITH AP.
PROVING AUTHORITY'S REQUIREMENTS OR l.OCAl. ORDINANCES.
PROPERTY NAME I DATE
Shepherds Path ?/e{..o? -
PROPERTY ADDRESS
13760 McKenna Road NW. Prior Lake MN ') ">1/
ACCEPTED BY APPROVING AUTHORITY('S) NAMES
Paul Baumgartner Fire Marshal
ADDRESS
PLANS 170'13.. Adelmann Street, Prior Lijke. MN 55372
...:;.'" INSTALLATION CONFORMS TO ACCEPTED Pl.ANS: YES KI NO 0
EQUIPMENT USED IS APPROVED o~ YES -Xl NO 0
IF NO, STATE DEVIATIONS
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION
OF CONTROl. VALVES AND CARE OF THIS NEW EQUIPMENT? YES Xl NO 0
IF YES, GIVE NAME. IF NO, EXPLAIN.
INSTRUC-
TIONS HAVE COPIES OF APPROPRIATE INSTRUCTIONS AND CARE AND MAINTENANCE YES Xl NO 0
CHARTS AND NFPA 13A BEEN LEFT ON PREMISES?
IF YES, GIVE NAME, IF NO. EXPLAIN.
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 static pressure In excess of, 150 PSI (10.3 bars). Dlfferentlal'drY-Plpe valve clappers shall be left open during test to
TEST prevent damage. All aboveground pipIng leakage shall be stopped.
DESCRIP-
TION PNEUMATIC: Establish 40 PSI (2.8 bars) air pressure and measure,~~ whlc:b .,hall n~t exceed 11/1 PSI (0.1 bars) in 24
hours. Test pressure tanks at normal water level and air pressure and meas . lilr ~ressur'i C;Op which shall not exceed 1'1.
PSI (0.1 bars) In 24 hours.
TESTS HYDROSTATIC: ALL PIPING. 2"
PNEUMATIC: DRY PIPING DRAIN
REQUIRED EQUIPMENT OPERATION: ALL. t "
- ,
SERVES Bl.DGt: ..... . . . , .
LOCATION --~""~~stem \ '...., ,.-:\ '. ~i ._'. .....; .... . \" I ~ -",...
~, ,
MAKE MODEL SIZE QUANT ITY TEMPERATURE RATING
SPRINKLERS Reliable F1FR 1/2 828 1550
.
OR TICO F.r.11 3/4 15 1')')0
SPRAY Reliabl~ FiRES 58 1/2 1554 1')')0
NOZZLES Globe GLQR 1/2 1550
100
TICO EC14 3/4 72 1')')0
MATERIAL AND KINO CONFORMS TO NFPA .j STANDARD
PIPE AND IF NONE, EXPLAIN
FITTINGS
ALARM DEVICE MAXIMUM TIME TO OPERATE THROUGH TEST PIPE
ALARM VALVE TYPE MAKE MODEL MIN. SEC.
OR FLOW Vane Potter VSR-F ~,
INDICATOR - -
FORM 85 AC. REVISED APRIL 1979
PRINTED IN U,S.A. FOR NAS .. FCA, INC., P.O. BOX 719, MT. KISCO. N.Y. 1054!
[]]
CONTRACTOR'S MATERIAL &: TEST CERTIFICATE
PARTS A 1& C - SPRINKLER 1& WATER SPRAY ABOVEGROUND PIPING (Fill Out Separate Certificate For Each Riser!
PROCEDURE
UPON COMPI.ETlON OF WORK, INSPECTION ANO TESTS SHAI.I. BE MADE BY THE CONTRACTOR'S REPRESENTATIVE AND WITNESSED BV
AN OWNER'S REPRESENTATIVE. ALl. DEFECTS SHAI.I. BE CORRECTED AND SYSTEM I.EFT IN SERVICE BEFORE CONTRACTOR'S MEN
FlNAI.I.Y I.EAVE THE JOB.
A CERTIFICATE SHALl. BE FII.I.ED OUT AND SIGNED BY BOTH REPRESENTATIVES, COPIES SHAI.I. BE PREPARED FOR APPROVING
AUTHORITIES, OWNERS AND CONTRACTOR. IT IS UNOERSTOOD THE OWNER'S REPRESENTATIVE'S SIGNATURE IN NO WAY PREJ-
UDICES ANY CLAIM AGAINST CONTRACTOR FOR FAUI.TY MATERIAl., POOP WORKMANSHIP, OR FAILURE TO COMPLY WITH AP-
PROVING AUTHORITY'S REQUIREMENTS OR LOCAl. ORDINANCES.
PROPERTY NAME I DATE
Shepherds Path 6- Ill- 0,
-
PROPERTY ADDRESS
13760 McKenna Road NW. Prior Lake MN Sl:ii7?
ACCEPTED BY APPROVING AUTHORITY('S) NAMES
Paul Baumgartner Fire Marshal
ADDRESS
PLANS 1701J,Adelmann Street. Prior L~ke. MN 55372
.\~~ INSTAI.I.ATION CONFORMS TO ACCEPTED PI.AN~: "i' YES Rl NO 0
EQUIPMENT USED IS APPROVED . -', YES 'Xl NO 0
IF NO, STATE DEVIATIONS
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO 1.0CATION YES m NO 0
OF CONTROl. VAI.VES AND CARE OF THIS NEW EQUIPMENT?
IF YES, GIVE NAME. IF NO, EXPI.AIN.
INSTRUC-
TIONS HAVE COPIES OF APPROPRIATE INSTRUCTIONS AND CARE AND MAINTENANCE YES ~ NO 0
CHARTS AND NFPA 13A BEEN I.EFT ON PREMISES?
IF YES, GIVE NAME, IF NO, EXPI.AIN.
HYDROSTATIC: Hydrostatic tests Shall be mllde at not less thlln 200 PSI (13.8 bllrs) for two hours or 50 PSI (3.4 bars)
lIbove sutie: pressure In excess of, 150 PSI (10.3 INIrs). Dlfferent..I'drY-PiPe vlllve clippers shill be left open during test to
TEST prevent damlge. All Iboveground Piping leaklge shill be stopped~
DESCRIP-
TION PNEUMATIC: Estlblish 40 PSI (2.8 IMrs) Ilr pressure Ind melsure droP(Whlc:h~'t!"not..xceed 11/, PSI (0.1 bars) in 24
hours. Test pressure tlnks It normll wlIter leve' Ind lir pressure Ind measure Ilr preSSure drop which shall not exceed 11/.
PSI (0.1 bars) In 24 hours.
TESTS HYDROSTATIC: ALl. PIPING. 2"
PNEUMATIC: DRY PIPING DRAIN i
REQUIRED EQUIPMENT OPERATION: ALL. '.
, "
f . . .
.;;~~$~:S:~ _ ~':: ; ...~.-- . -~.., "'''Oc,:
LOCATION . , . , ,...~ .
.' ,
.
MAKE .I I" MODEL SIZE QUANT ITY TEMPERATURE RATING
SPRINKLERS
OR
SPRAY
NOZZLES
MATERIAl. AND KINO CONFORMS TO NFPA13 STANDARD
PIPE AND IF NONE, EXPI.AIN
FITTINGS
-
AI.ARM DEVICE MAXIMUM TIME TO OPERATE THROUGH TEST PIPE
ALARM VALVE TVPE MAKE MODEL MIN. SEC.
OR FLOW Vane Potter VSR-F ~?
INDICATOR
FORM 85 AC. REVISED APRIL 1979
PRINTED IN U.S.A. FOR NAS . FCA. INC., P.O. BOX 719, MT. KISCO. N.V. 1054'
J1J \. ,~~ONT~cro~~,M~R~L ~TI:S~ CERTIFICATE
PARTS .A & C - SPRINKL.ER & WATER SPRAY ABOVEG'AOU!lft:S PIPING IFill Out Separate Certificate For Each Riser)
PROCEDURE
UPON COMPLETION OF WORK, INSPECTION ANO 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 MEN
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 PREJ.
UDICES ANY CLAIM AGAINST CONTRACTOR FOR FAULTY MATERIAL. POOP WORKMANSHIP. OR FAILURE TO COMPLY WITH AP.
PROVING AUTHORITY'S REQUIREMENTS OR LOCAL ORDINANCES.
PROPERTY NAME 1 DATE
Shepherds Path I?~ ftI..o?
PROPERTY ADDRESS
13760 McKenna Road NW Prior l..q ke MN 1)1) ~7?
ACCEPTED BY APPROVING AUTHORITY('S) NAMES
Paul Baumgartner Fire Marshal
ADDRESS
PLANS 170'13. Adelmann Street, Prior L@ke, MN 55372
~. ;: ,'I INSTALL.ATION CONFORMS TO A~~ED PL.ANS: _ (" . YES Itl NO 0
fl.... EQUIPMENT USED IS APPROVED ;0 ,~; .. YES -XJ NO 0
IF NO. STATE DEVIATIONS
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION
OF CONTROL VAL.VES AND CARE OF THIS NEW EQUIPMENT? YES XI NO 0
IF YES, GIVE NAME. IF NO, EXPL.AIN.
INSTRUC-
TIONS HAVE COPIES OF APPROPRIATE INSTRUCTIONS AND CARE AND MAINTENANCE YES XI NO 0
CHARTS p,ND NFPA 13,0. BEEN L.EFT ON PREMISES?
IF YES, GIVE NAME, IF NO, EXPL.AIN.
HYDROSTATIC: Hyarostatlc tests shall be maa. at not less than 200 PSI (13.8 bars) for two hours or 50 PSI (3.4 bars)
above static pressure In excess of, 150 PSI (10.3 bers). Dlfferent..1 c1ry.plpe valve cleppers snell be left open a ur ing test to
TEST prevent c1emage. All ebovegrouna pIpIng 'uleave shall be stoppea~
DESCR IP.
TION 5' ,;.' . 2
PNEUMATIC: Estebllsh 40 PSI (2.8 bars) elr pressure ana meesure ,w~lclI n. not ltl'lIFeed 11/2 PSI (0.1 bars) In 4
hOurs. Test pressure tenks et normel weter I."el end air preHure ena m.. reelr pr.su're arop which shall not exceea 11/.
PSI (0.1 ben) In 24 hours.
TESTS HYDROSTATIC: ALL. PIPING. 2"
PNEUMATIC: DRY PIPING DRAIN
REQUIRED EQUIPMENT OPERATION: A l..L. , '.
..., .
SERVEs~DGS: t-. . .... '-
LOCATION ,",,- "''!)1-"c..~stem' 12 -- "~ ' <'. . ..... ,. -.,"",.,- .,'\ . ., ~
,'.
MAKE MODEL. SIZE QUANTITY TEMPERATURE RATING
SPRINKLERS Reliable F1FR 1/2 161 2000
OR TYCO BB1 17/32 56 2000
SPRAY TYCO DS-C 1/2 5 11)50
NOZZLES
MATERIAL. AND KIND CONFORMS TO NFPA 3 STANDARD
PIPE AND I F NONE. EXPLAIN
FITTINGS
AL.ARM DEVICE MAXIMUM TIME TO OPERATE THROUGH TEST PIPE
ALARM VALVE TYPE MAKE MODEL MIN. SEC.
OR FLOW Pressure Potter PS10 /11-
I INDICATOR -
I
FORM 85 AC, REVISED APRIL 1979
PRINTED IN U.S.A. FOR NAS & FCA, INC., P.O. BOX 719. MT. KISCO. N.Y. 1054
---",.,...".................--.'......"..;...'-,-.".,,_.~
(Ol
.~~. ~ -!,:'t
PARTS A a C - SPRINKLER
CONTRACTOR'S MATERIAL & TEST CERTIFICATE
,-' \, \~~~., r".
a WATER SPRAY ABOV~dROUND PIPING (Fill Out Separate Certificate For Each Rised
PROCEDURE
UPON COMPL.ETION OF WORK, INSPECTION AND TESTS SHAL.L. BE MADE BV THE CONTRACTOR'S REPRESENTATIVE AND WITNESSED BY
AN OWNER'S REPRESENTATIVE. AL.L. DEFECTS SHAL.L. BE CORRECTED AND SYSTEM L.EFT IN SERVICE BEFORE CONTRACTOR'S MEN
FINAL.L.V L.EAVE THE JOB.
A CERTIFICATE SHAL.L. BE FIL.L.ED OUT AND SIGNED BV BOTH REPRESENTATIVES. COPIES SHAL.L. BE PREPARED FOR APPROVING
AUTHORITIES, OWNERS AND CONTRACTOR. IT IS UNDERSTOOD THE OWNER'S REPRESENTATIVE'S SIGNATURE IN NO WAY PREJ-
UDICES ANV CL.AIM AGAINST CONTRACTOR FOR FAUL.TV MATERIAL., POOP WORKMANSHIP, OR FAIL.URE TO COMPLY WITH AP-
PROVING AUTHORITV'S REQUIREMENTS OR L.OCAL. ORDINANCES.
PROPERTY NAME ID':lq..a~
Shepherds Path
PROPERTY ADDRESS
13760 McKenna Road NW. Prior LakE" MN "'\"'\ ~ /'/
ACCEPTED BV APPROVING AUTHORITY('S) NAMES
Paul Baumgartner Fire Marshal
ADDRESS
PLANS 170'13., Adelmann Street, Prior L~ke. MN 55372 I
"I.. .:~ ~,J INSTAL.L.ATION CONFORMS TO ACCEPTED PLANS:~~' \ YES ttI NO 0
EQUIPMENT USED IS APPROVED " J YES 'Xl NO 0
IF NO, STATE DEVIATIONS
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO L.OCATION
OF CONTROL. VAL.VES AND CARE OF THIS NEW EQUIPMENT? YES Xl NO 0
IF YES, GIVE NAME. IF NO, EXPL.AIN.
INSTRUC.
TIONS HAVE COPIES OF APPROPRIATE INSTRUCTIONS AND CARE AND MAINTENANCE NO 0
CHARTS AND NFPA 13A BEEN L.EFT ON PREMISES? YES Xl
IF YES, GIVE NAME. IF NO, EXPL.AIN.
HVDROSTATlC: Hydrostatic tests shall b. made at not less than 200 PSI (13.8 bars) for two hours or 50 PSI (3.4 bars)
abov. static pressure In excess of, 150 PSI (10.3 bIIrs). Dlfferent..I dry-pipe valve clappers shall be left open during test to
TEST prevent damage. All aboveground piping leakage shall be stopped,
DESCR Ip.
I' ~ ",
TION PNEUMATIC: Establish 40 PSI (2.8 bIIrs) air pressure and measure drop I&""al, _\ exceed 111I PSI (0.1 bars) in 24
hours. Test pressure tanks at normal water 1..,.1 and air pressure and measure air prlllSure drop which shall not exceed 11/.
PSI (0.1 bars) In 24 hours.
TESTS HVDROSTATIC: AL.L. PIPING. 2"
PNEUMATIC: DRY PIPING DRAIN
REQUIRED EQUIPMENT OPERATION, A L.L.. , .,
SERVES' BI.DGS; . . .
. . ~. " "
LOCATION '...-. l~l.-" (.~. .... '~ \ .. . . .. .)~- .~.. ~':"
'*1' .
rv " .
MAKE MODEL. SIZE QUANT ITV TEMPERATURE RATIN!
SPRINKLERS Reliable F1FR 1/2 t62 2000
OR TIeO BB1 17/32 57 2000
SPRAY TIeO DS-C 1/2 5 1550
.
NOZZLES
MATERIAL. AND KIND CONFORMS TO NFPA 1'3 STANDARD
PIPE AND IF NONE, EXPL.AIN
FITTINGS
AL.ARM DEVICE MAXIMUM TIME TO OPERATE THROUGH TEST PIPE
ALARM VALVE TVPE MAKE MODEL. MIN. SEC.
OR FLOW Pressure Potter PS10 /0
INDICATOR - - -
FORM 85 AC. REVISED APRIL. 1979
PRINTED IN U.S.A. FOR NAS &. FCA, INC., P.O. BOX 719, MT. KISCO, N.Y. 105'
OPERATING TEST RESULTS:
TIME TO TRIP TIP TIME WATER ALARM
MAKE MODEL SER. THROUGH TEST PIPE WATER AIR 'POINT REACHED OPERATED
DRY NO. WITHOUT. WITH PR.ESS. PRESS. AIR TEST
Q.O. D. 'Q.O.D. PRESS. OUTLET PROPERLY
PIPE MIN. SEC. MIN. SEC. P.S.I. P.S.I. P.S.I. MIN. SEC. YES NO
V A LV ES
IF NO, EXPLAIN
OPERATION PNEUMATIC 0 ELECTRIC 0 . HVDRAUL.IC 0
PIPING SUPERVISED: YES 0 NO 0 DETECTING MEDIA SUPERVISED: YES 0 NO 0
DELUGE DOES VAL.VE OPERATE FROM THE MANUAL. TRIP ANDIOR REMOTE CONTROL STATIONS? YES 0 NO 0
& IS THERE AN ACCESSIBL.E FACILITV IN EACH CIRCUIT FOR TESTING? YES 0 NO 0
IF NO, EXPLAIN
PREACTION
V A LV ES Do~~Each Circuit Operate Does each Circuit Operate Maximum Time To
MAKE MODEL Su rvision Loss Alarm? Valve Release? ODerate Release:
..... .,., YES I NO 'YES I NO MIN. SEC.
\ ~l..~ ..... ()
I I
ALL PIPING HVDROSTATICALLV TESTED AT 200 PSI FOR 2 HOURS
DRV PIPING PNEUMATICALLV TESTED: YES }CC NO 0
EQUIPMENT OPERATES PROPERL V: VES~ NO 0
TESTS IF NO, STATE REASON
DRAIN TEST: READING OF GAGE LOCATED RESIDUAL. PRESSURE WITH VAL.VE IN
NEAR WATER SUPPL.V TEST PIPE: /00 TEST PIPE OPEN WIDE PSI9~
STATIC PRESSURE PSI
NUMBER USED I L.OCATIONS INUMBER REMOVED
TEST BLANKS none
WELDED PIPING YES xx NO 0
IF VES...
DO YOU CERTIFV AS THE SPRINKLER CONTRACTOR THAT WEL.DING PROCEDURES COMPLY ~H THE REQUIRE-
MENTS OF AWS 010.9, LEVEL AR.3? YES NO 0
WELDING DO YOU CERTIFV THAT THE WELDING WAS PERFORMED BV WEL.DERS QUAL.IFIED IN COMPL.IANCE WITH THE
REQUIREMENTS OF AWS 010.9, LEVEL AR.3? YES jk NO 0
DO YOU CERTIFV THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A DOCUMENTED QUALITV CON.
TROL. PROCEDURE TO INSURE THAT ALL. DISCS ARE RETRIEVED; THAT OPENINGS IN PIPING ARE SMOOTH,
THAT SLAG AND OTHER WEL.DING RESIDUE ARE REMOVED, AND THAT THE INTERNAL. DIAMETERS OF
PIPING ARE NOT PENETRATED? VES~ NO 0
DATE L.EFT IN SERVICE WITH AL.L. CONTROL. VAL.VES OPEN:
REMARKS 6'- It.!- D/
NAME OF SPRINKL.ER CONTRACTOR
Total Fire Protection, Inc.
FOR P7;.Ll:i(S~ TITLE
SIGNATURES (../1{... 0'1 ';'~~I
FOR SPRINKLER C6NTRACTOR (SIGNED)
TESTS WITNESSED BV TITL.E DATE
ADDITIONAL. EXPLANATIONS AND NOTES
~'~
OPERATING TEST RESULTS:
TIME TO TRIP TIP TIME WATER ALARM
MAKE MODEL SER. THROUGH TEST PIPE WATER AIR JIOINT REACHED OPERATED
DRY NO. WITHOUT WITH PR.ESS . PRESS. AIR TEST PROPERLY
Q.O. D. ' Q,O.D. PRESS. OUTL.ET
PIPE MIN. SEC. MIN, SEC. P.s.I. P,S,I. P.S.I. MIN. SEC. VES NO
V A LV ES
IF NO. EXPLAIN
OPERATION PNEUMATIC 0 EL.ECTRIC 0 HVDRAUL.IC 0
PIPING SUPERVISED: VES 0 NO 0 DETECTING MEDIA SUPERVISED: VES 0 NO 0
DELUGE DOES VALVE OPERATE FROM THE MANUAL. TRIP AND/OR REMOTE CONTROL. STATIONS? YES 0 NO 0
& IS THERE AN ACCESSIBL.E FACIL.ITV IN EACH CIRCUIT FOR TESTING? YES 0 NO 0
IF NO. EXPLAIN
PREACTtON
V A LV ES Does Each Circuit Operate Does I8ch Circuit Operate Maximum Time To
MAKE MODEL Supervision Loss Alarm? Valve Release? ODllrate Rell8se:
\~ .'~\ ..:' YES I NO YES I NO MIN. I SEC.
I I
ALL PIPING HVDROSTATlCAL.L.Y TESTED AT 200 PSI FOR 2 HOU RS
DRY PIPING PNEUMATlCAL.L.Y TESTED: YES }(JC NO 0
EQUIPMENT OPERATES PROPERLY: YES Jm NO 0
TESTS IF NO, STATE REASON
DRAIN TEST: READING OF GAGE LOCATED RESIDUAL PRESSURE WITH VALVE IN
NEAR WATER SUPPLY TEST PIPE: /00 TEST PIPE OPEN WIDE ~
STATIC PRESSURE PSI PSI
NUMBER USED L.OCATlONS I NUMBER REMOVED
TEST BLANKS none
WEL.DED PIPING YES xx NO 0
IF YES...
DO YOU CERTIFV AS THE SPRINKLER CONTRACTOR THAT WEL.DING PROCEDURES COMPL.V ;'8lH THE REQUIRE.
MENTS OF AWS 010.9, L.EVEL. AR.3? YES NO 0
WELDING DO you CERTIFV THAT THE WELDING WAS PERFORMED BY WEL.DERS QUAL.IFIED IN COMPL.IANCE WITH THE
REQUIREMENTS OF AWS 010.9, L.EVEL. AR.3? YES Jik NO 0
DO YOU CERTIFV THAT WELDING WAS CARRIED OUT IN COMPL.IANCE WITH A DOCUMENTED QUALITY CON.
TRDL. PROCEDURE TO INSURE THAT AL.L. DISCS ARE RETRIEVED; THAT OPENINGS IN PIPING ARE SMOOTH,
THAT SL.AG AND OTHER WEL.DING RESIDUE ARE REMOVED, AND THAT THE INTERNAL. DIAMETERS OF
PIPING ARE NOT PENETRATED? YES X3c NO 0
DATE L.EFT IN SERVICE WITH AL.L CONTROL VALVES OPEN:
REMARKS h-/t(.. 0/
NAME OF SPRINKL.ER CONTRACTOR
Total Fire Protection, Inc.
FOR PROPERTY OWNE~Z) TITL.E
SIGNATURES PlJ/. 6../~..e>? "f;". __
FOR SP~INKL.ER CONTRACTOR (SIGNED) ~ r-...tQrt
. '",
TESTS WITNESSED BY TITL.E DATE
ADDITIONAL. EXPLANATIONS AND NOTES
~-~
OPERATING TEST RESULTS:
TIME TO TRIP TIP TIME WATER ALARM
MAKE MODEL SER. THROUGH TEST PIPE WATER AIR 'POINT REACHED OPERATED
DRY NO. WITHOUT, WITH PR,ESS. PRESS, AIR TEST
Q.o. O. . Q.O. D, PRESS. OUTLET PROPERLY
PIPE MIN. SEC. MIN. SEC. P.5.I, P.S.I. P,S.I, MIN. SEC. YES NO
V A LV ES g. .. r 16 'II. 1(0 rO I K> IX
TICO DPVl 6"
I F NO, EXPLAIN
OPERATION PNEUMATIC 0 EL.ECTRIC 0 HYDRAUL.IC 0
PIPING SUPERVISED: YES 0 NO 0 OETECTING MEDIA SUPERVISED: YES 0 NO 0
DELUGE DOES VALVE OPERATE FROM THE MANUAL. TRIP AND/OR REMOTE CONTROL. STATIONS? YES 0 NO 0
& IS THERE AN ACCESSIBL.E FACILITY IN EACH CIRCUIT FOR TESTING? YES 0 NO 0
IF NO, EXPLAIN
PREACTION
VALVES eoes EACh Circuit Operate Does uch Circuit Operate Maximum Time To
MAKE MODEL Supervision Loss Alarm? Valve Rella.? ODllrate Reluse:
(' c 4">' ~-c YES I NO YES I NO MIN. SEC.
\', . I I
AL.L PIPING HYDROSTATICALL.Y TESTED AT 200 PSI FOR 2 HOURS
DRY PIPING PNEUMATICALLY TESTED: YES XX NO 0
EQUIPMENT OPERATES PROPERLY: YES~ NO 0
TESTS IF NO, STATE REASON
DRAIN TEST: REAOING OF GAGE L.OCATED RESIDUAL. PRESSURE WITH VAL.VE IN
NEAR WATER SUPPLY TEST PIPE: /00 ~ TEST PIPE OPEN WIDE 96
i STATIC PRESSURE PSI PSI
NUMBER USED I L.OCATlONS I NUMBER REMOVED
TEST BLANKS none
WELDED PIPING YES XX NO 0
IF YES...
DO you CERTIFV AS THE SPRINKL.ER CONTRACTOR THAT WELDING PROCEDURES COMPL.V ~H THE REQUIRE.
MENTS OF AWS DI0.9, LEVEL. AR.3? YES NO 0
WELDING 00 yOU CERTIFY THAT THE WELDING WAS PERFORMED BY WEL.DERS QUALIFIED IN COMPL.IANCE WITH THE
REQUIREMENTS OF AWS 010.9, L.EVEL. AR.3? YES ik NO 0
00 YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A DOCUMENTED QUAL.ITY CON.
TROL PROCEDURE TO INSURE THAT ALL. DISCS ARE RETRIEVW; THAT OPENINGS IN PIPING ARE SMOOTH,
THAT SL.AG AND OTHER WEL.DING RESIDUE ARE REMOVED, AND THAT THE INTERNAL. DIAMETERS OF
PIPING ARE NOT PENETRATED? YES}(3c NO 0
DATE L.EFT IN SERVICE WITH ALL CONTROL VALVES OPEN:
REMARKS b - /9. O~
NAME OF SPRINKL.ER CONTRACTOR
Total Fire Protection, Inc.
FORp:7/;.R ~D~ TITLE
SIGNATURES 6 -- I t/- ~ 7 hr',..__._
FoA SPRINKLER CONTRACTOR (SIGNED)
TESTS WITNESSED BY TlTL.E DATE
ADDITIONAL EXPL.ANATIONS AND NOTES
~\
. "
DRY
PIPE
VALVES
DELUGE
&
PREACTlON
VALVES
""~..',~, "
'.' .," e:.
reSTS
TEST BLANKS
i .~ --
<'
WELDING
REMARKS
SIGNATURES
OPERATING TEST RESULTS:
MAKE MODEL
TIME TO TRIP TIP TIME WATER ALARM
THROUGH TEST PIPE WATER AIR ~INT REACHED OPERATED
WITHOUT, WITH PR.ESS. PRESS. AIR TEST PROPERLY
Q. O. D. Q.O. D. PRESS. OUTL.ET
MIN. SEC. MIN, SEC. P.s.I. P.s.I. P.S.'. MIN. SEC. YES NO
/0 '/~(,} VO 7!~ tfo )(
SER.
NO.
TICO
6"
DPVl
IF NO, EXPLAIN
OPERATION
PNEUMATIC 0
YES 0
EL.ECTRIC 0
HYDRAUL.IC 0
o
o
NO 0
NO 0
NO 0
PIPING SUPERVISED:
NO 0
DETECTING MEDIA SUPERVISED:
YES
DOES VAL.VE OPERATE FROM THE MANUAL. TRIP AND/OR REMOTE CONTROL. STATIONS?
yES
IS THERE AN ACCESSIBL.E FACIL.ITY IN EACH CIRCUIT FOR TESTING?
IF NO, EXPL.AIN
YES 0
MAKE
Does Eilch Circuit Oper.te
Supervision Loss Alarm?
YES I NO
I
200
Does each Circuit Operate
Valve Release?
'YES I NO
I
Maximum Time To
ODtlrate Release:
MIN. SEC.
MODEL.
FOR 2
YES }(X
YES }GlI
ALL PIPING HYDROSTATICALLY TESTED AT
DRY PIPING PNEUMATICALLY TESTED:
EQUIPMENT OPERATES PROPERLY:
IF NO, STATE REASON
PSI
HOU RS
NO 0
NO 0
DRAIN TEST: READING OF GAGE LOCATED
NEAR WATER SUPPL.Y TEST PIPE: h"'\....
STATIC PRESSURE ~__
T L.OCATIONS
RESIDUAL. PRESSURE WITH VALVE IN
TEST PIPE OPEN WIDE
PSI
PSI 9t:;/
NUMBE R USED
I NUMBER REMOVED
none
WELDED PIPING YES xx NO 0
IF YES...
DO YOU CERTIFV AS THE SPRINKL.ER CONTRACTOR THAT WELDING PROCEDURES COMPL.Y WiTH THE REQUIRE.
MENTS OF AWS 010.9, LEVEL. AR.3? YES ~ NO 0
DO YOU CERTIFY THAT THE WEL.DING WAS PERFORMED BV WELDERS QUAL.IFIED IN COMPL.IANCE WITH THE
'REQUIREMENTS OF AWS 010.9, L.EVEL AR.3? YES JBc NO 0
DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPL.IANCE WITH A DOCUMENTED QUAL.ITY CON.
TROL PROCEDURE TO INSURE THAT ALL DISCS ARE RETRIEVEO; THAT OPENINGS IN PIPING ARE SMOOTH,
THAT SL.AG AND OTHER WELDING RESIDUE ARE REMOVED, AND THAT THE INTERNAL DIAMETERS OF
PIPING ARE NOT PENETRATED? YES ~ NO 0
DATE LEFT IN SERVICE WITH ALL CONTROL. VAL.VES OPEN:
./- / II-/!) .,
NAME OF SPRINKLER CONTRACTOR
Total Fire Protection, Inc.
FO/11~ /N~;;ED)
FOR SPRINKL.ER CONTRACTOR (SIGNED)
TITLE
b- /~.. e ., ;:::~,__
,
TESTS WITNESSED BV
TITL.E
ADDITIONAL. EXPL.ANATlONS AND NOTES
DATE
,-.'
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