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1:'1coj Fire ~ / Si.npf,xt;rinnell
, SecurIty -.qk~/o)
REPORT OF INSPECTION Ai ~
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REPORTTn, ~,V\.'r F \1 E.) co ~ 1\ tis
STREET I ~c~?~ f Rj:\,~\::::,U I\l lK
CITV&STATF t'~\oR LAKE:.. MN. ZIP~?')d.
,
."PECTION F EPORT
NO.
CONFEflRED I VITH
SHJ\ \ l'.\f',
INS~Te;~~~ACT
NO."""", "'" "'" "'"",'..""",..""""""".
BUREAU FILE
NO..
SET 1 OF 2
:::,I-\nt:. '
BUILDING O~L09Nl9N IU;;PECTED
INSPECTOR u l~ ...l
GRINNEL~p Fir" l-'LYMoVI'''-. PHONE NO ~l..' I-~
OAT" L.j - '-i - OS
Pressure Fire Pump & Tank
Pressure Fire Pump & CiIY~~ \
Pressure Fire Pump & Pond t
Size Static Stalic
Test Pressure Flow Pressure
Pice Before Pressure After
ATT.
1. GENERAL
A. (To be ans~ 'ared by the Owner or Owner's representative)
a. Have thl re been any changes in the occupancy classification, machinelY or operations since the last inspection?
b. Have 1hl ra been any changes or repairs to the fire protection systems since the last inspection?
c. If a fire I ;as occurred since the last inspection, have all damaged sprinkler system components been replaced?
d. Has the Jiping in all dry systems been checked for proper pitch within the past five years? f\l E W \ N d.. <:> ~ ..~
Date las checker! (checking is recommended at least every 5 years)
e. Has the Jiping in all systems been checked for obstructive materials?
Date las checker! (checking is recommended at least every 5 years)
f. Have all fire pumps been tested to their full capacity through the use of hose streams or flow meters within the past 12 months?
g. Are gra\ ty, surface or pressure tanks protected from freezing?
h. Are any Jf the sprinklers 50 years old or older? (testing anellor replacement is recommended for such sprinklers)
Are any ~xtra high temperature solder sprinklers regularly exposed to temperatures near 3000F?
B. (To be ans\ 'ered by.the inspector)
a. Have thi ! sprinkler systems been extended to all visible areas of the building?
b. Does thl Ire appear to be proper clearance between the top of all storage and the sprinkler deflector?
c. Are the luilding areas protected by a wet system, heated, including its blind attics and perimeter areas, where accessible?
d. Are all " sible exterior ooeninas orotected aQainst the entrance of cold air?
2. CONTROL VAL tES
a. Are all s lonkler system main control valves and all other valves in the appropriate open or closed position?
b. Are all c mtral valves sealed or supervised in the open position?
No, Easily Valve Secured?
Contrt I of Type Accessible Signs Open If ves, how? (Sealed?)
Valve' (Locked?)
V~ves yV' No Ve.... No V, No Yew No (SuDvd.?)
CITY CONNE ;TION d. t"',V ,'u-.::; 1 V y ""l-\~'y l\
TANK .
- \-'> ;,'Y \ ~y if V V v. ",,^i"v~
SECTIONAL IT \-,,1"\:. -~ -y, 'C~ if ~ V/ Loc.k.l:.
SYSTEM ,;,[ Y V ". ,>0\ ~VD
ALARM LINE
Ci" ~\()R L'A,\<:,"i:.
Np,
3. WATER SUPPL ES
a. Water supply source?
Waterflow Test Ref'ulls Made During This Inspection
Test Size Static
Pipe Test Pressure
_ Locate j E'.ioe ...sefire
,",l''' ';c u: \ ,...l" I X
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<:,.C'Nl::. ......., ci..
Gravity Tank
.:::,~
Static
Pressure
'-"Km'>
I <
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Test
Pipe
Location
Flow
~ssr;
, .....
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,'?,
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4. TANKS, PUMP! , FIRE DEPT. CONNECTIONS
a. Do fire pump ;, gravity, surface or pressure tanks appear to be in good external condition?
b. Are gravity, S jrface and pressure tanks at the proper pressure and/or water levels?
c. Are fire dept. connections in satisfactory condition, couplings free, caps or plugs in place and check valves tight?
d. Are fire dept. connections visible and accessible?
5. WET SYSTEMS ~
a. No. of systen s N... Make & Model W c.. '\
b. Are cold wea her valves in the appropriate open or closed position?
If closed, has piping been draine...l?
c. Has the ownl r or owner's representative been advised that cold weather valves are not recommended by NFPA?
d. Have aU the lntifreeze systems been testerl?
e. Date antifree :e systems were te""'o...l
f. The antifreez l tests indicate protection fn'
system 1 2 3 4
............. .. .g~ Did ala.~m valles, waterflow alarm indicators and retards test satisfactorily?
.
P \~ =.
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temperature
Yes .. N~
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Supervision
Operational
Yes./ No
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Yes N.A.:V No~
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SG455~-R2-;
INSURANCE BUREAU COPY
:j:NolApplicable
"Explain (No) Answers on Back of Sheet 2
INSPECTION 1EPORT
NO.
'tqeD/ Fire ~ / Si_pl.xGri"".,1
Security LI_ \9-05"
REPORIOFINSf:>EbION
I\Pi-S
BLLAI"'f'
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...~.,
INSPECTION CONTRACT
NO.~"J(QS9.~ .
BUREAU FILE
NO.
6. DRY SYSTEM: -
a. No. of Systl IT"" Make & Model!') C c..;, ,-~ ~
Date last Ir ) lesten
b. Is the air pi 3ssure and priming water levels normal?
c. Did the air :ompressor operate satisfactorily?
d. Were all 10\ , points drained during this inspection?
e. Did all quic : opening devices operate satisfactorily?
t. Did all the I Iry valves operate satisfactorily during this inspection?
g. Do dry vall< ~s appear to be protected from freezing?
h. Is the dry v ilve house healed?
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7. SPECIAL SYS rEMS
a. No. of systl ms
Type
b. Were valve; tested as required?
c. Did all heal responsive systems operate satisfactorily?
d. Did the sUf. ervisory teatures-operate dUring testing?
Heat Responsi /e Devices: TypE"
Valve No, 1......2.
Valve No 1. .2..
Valve No 1......2.
Valve No 1......2.
C",
('-:,
Make & Model
t,.~
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Auxiliary equip nent:
No.
Location
Test result<>
....3.... ..4.
..3.... ..4.
... .3..... .4.
.... .3. .. .4.
Ty"""
Type of te<:,"
.... .5......6. Valve No,
.... .5......6. Valve No
.....5..... .6. Valve No,
.....5......6. Valve No
~, ,1\
1. ....2......3......4. .5.
1......2......3......4......5.
1......2......3......4......5.
1......2......3......4. .5.
..6.
.., ..6.
.6.
.... .6.
8. ALARMS
a. Did the wa 3r motors and gong operate during testing?
b. Did the ele :tric alarms operate during testing"
c. Did the su~ ervisory alarms operate during testing?
9. SPRINKLERS - PIPlNG
a. Do sprinkle 'S generally appear to be in good external condition?
b. Do sprinkle 'S generally appear 10 be free of corrosion, paint, or loading and visible obstructions?
c. Are extra S Hinklers available on the premises? ' , ...__ ,_.,
d. Does the e derior condition of piping, drain valves. check valves, hangers, pressure gauges, open sprinklers
and straine 'S appear to be satisfactory?
e. Does the h md hose on the sprinkler system appear to be in satisfactory condition?
10. EXPLANATIO \I OF "NO" ANSWERS (For Sections 18 thru 9):
Ves N.A.t No'
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11, T~E INSPECT)R ~GGES,,[S THE F9LLOWI~G NE~ARY IMP~VEMENTS, HQWEVER"THESE SUGGESTIONS ARE NOT THE RESULT OF A~NGINEERING SURVEY:
.......)'t:.c
-::C~, VI"} I::' 1"\ '" to \'1-\'-
12. ADJUSTMEN"S OR CORRECTIONS MADE:
/
13. LIST CHANGE S IN THE OCCUPANCY HAZARD OR FIRE PROTECTION EQUIPMENT, AS ADVISED BY THE OWNER IN SECTION 1A:
/
14. I~SPECTION j .ND SUGGESTED IMPRO~E~TS wm(~~SS~D >>,111:1 Tflf ~:~GNED OWNER OR OWNER" REPR~~N~A~yq
Signature of owner or owner's representative - - 'i - - -, l I U t "_. Dale -=J - l' ()C..."
DUPLICATE TO:
STREET
CITY & STAT~
ATT
SG4550R1-2
ZIP
-t:Not Applicable
.Explain (No) Answers on Back of Sheet
INSURANCE BUREAU COPY
INSPECTIO~ REPORT NO.
I ~.rI~'U~
1:LJCD Fire ~ /SimPleXGrinnell
Security
BLu;f f. 11 E.; ~ "\"i-S f\ PT
INSPE;TION CONTRACT NO. c:,. ") ~ "'S"' "1 ~
CONFERRer WITH S \4 h'\ "'H~.
BUREAU FILE NO.
SUPPLEMENTAL RECORD OF INSPECTION
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G4550R 1,3
WHITE - Office YELLOW - Freid PINK - Customer
1:'1CajFire ~ / SimplexGrinnell
Security
DRY PIPE VALVE TRIP TEST REPORT
FOR R ~ I' ~j::. 1-\ Be:. ~ /.\ PT'E: INSPECTION NO. .Q c... ~ CI '"
STREET .!G,J;;'~"5<' ' E:&nt\1c:'l ~ ,,\ -;:j( crr~~Q LAt:::E. STtTE CONTRACT NO,
DATE OF TRI' TEST 4 .... I '=I ~ Ci ~ INSPECTOR t\, (") DAY WORK NO.
NOTE: BE =ORE ANY DRY PIPE VALVE IS TRIP TESTED, THE WATER SUPPLY LINE TO Q SHOULD BE TH ROUGHLY FUJSHED. THE TWO INCH DRAIN BELOW
TH ~ VALVE SHOULD BE OPENED WIDE, AND WATER AT FULL PRESSURE SHOULD BE DISCHA GED LONG ENOUGH TO CLEAR THE PIPE OF ANY
AC :UMULATlON OF SCALE OR FOREIGN MATERIAL. IF THERE IS A HYDRANT ON THE SUPPLY LINE, THIS HYDRANT SHOULD BE FUJSHED BEFORE
-'fH :-'TWO-tNCI-tDRAII\, ...::. .....,... ",.../EO; THf:nRlPVALVF """'\1 1111:: uRY PrPE-VALVE-SHOOCD-ee-CHI::......."l::l.1 oEFORE'TRlr-r-INu I Mt:; vR"i'"""P1PE VALVE. TO SEE
TH loT IT IS IN OPERATING CONDlTION.
_._._-_...,--------_.._---,~._--".,~.
SYSTEM NO. (
I
I
I
I
INCHI
(IRY PIPE VALVES
VALVE SERIAL \lUMBER
MANUFACTURE ~ (NAME)
VALVE MODEL
VALVE SIZE
CONTROLLING :;PRINKLERS
I (LOCATION)
I (NUMBERI
DATE LAST TRIP TESTED?
DATE LAST OPI :RATED?
I AIR
I WATER
SIZE AND LOC,lI nON OF TEST VALVE
PRESSURE BE =ORE TEST
WAS GATE VALVE IELOW DRY VALVE OPEN WIDE ATTEST71
(IF NOT, HOW MAN 'TURNS?)
I AIR PRESSURE
I WATER PRESSURE)
J TIME
IF SYSTEM FLO )DED, LIST TIME WATER
REACHED TES,. OPENING
VALVE TRIPPI:O AT
PERFORMANCE
VALVE CONOl' -ION
jlNTERIOR OF BODyl
I MOVING PARTS I
I AUBBER FACING I
I SEATS I
I RESET? I
DID ALAAMS OF :oRATE AT TRIP TEST?
ALL LOW POINT DRAINS BLOWN OUT?
WATER CONTRQL VALVE LEFT
OPEN AND SEAU.ED?
ALARM CONTR~L VALVE LEFT
OPEN AND SEAt;.ED?
aUICI: OPENING DEVICES
DEVICE SEAIAL \lUMBEA
MANUFACTUREII (NAME)
TYPE AND MODI oL
AlA PAESSUAE N UPPER CHAMBER
QUICK OPENING DEVICE TRIPPED AT
PERFORMANCE
QUICK OPENING DEVICE LEFT IN SERVICE
AND CONTROL ( 'PEN AND SEALED?
LIST ANY UNS. I.TI$FACTORY CONDITIONS:
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lBsl
MIN SEcl
MIN SECI
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SEC
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REMARKS ~,' 1 :o:;.-i ,,\
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COARAc.l.': ~fj/~"$?
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SG 4274 R4
SYSTEM NO. (
INCHI
(APPROXII
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lBSI
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lBS
MIN SEcl
MIN SEcl
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SYSTEM NO. (
SEC
lBSI
lBS
SYSTEM NO.
INCH
(APPROX)
lBS
lBS
lBS
lBS
MIN SEC
MIN SEC
SYSTEM NO. (
SEC
lBS
lBS