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Home My WebLink AboutFire Inspection Report ... fFiRl& I - . .', . ~.." '. '. . "-,, -. ." .:' 'sfIcu,ily.' . . . cCl1QN REIooRr NO, .CQNFEflREQ WITH I ~,a.f\ --~Q ~~. - ,ATt." .. " '^""H','_ . i- _ '" .,., ':.-"';.'" .',i':.' ~ ",",_ ___ ..11'_111,.1..,..," _,,"__ f.'{lHU . : - ---,- ^- '.' . A;"::{JotHl:'i.",.,_, tiJthe~'or~:'M-~".Jtd.iDJ " . '. . ,'_. ."..,._;::,' ";::h::~=~t~~:='::.~?~~;"C=:d. . d. Halthe.~,rdry"r"'""~~iorJllllillltpiloh._thepos{fiwt~~ , I1iIfrIIllot ,-.,g.. ..,. a. Halthe.."'....,.._<Ihod!loII._-...,., "...7 . "," _1aoI_ . . ""',..'. . - .)'"~'''\~'\..Is.''' ".lIt.~!;._l ~" ~:;,!~~'~.:~t!!~I~[:.'I,..:ii~Yl.. ~.:'-,.,~-:i~;<~~~~~.~I_~"~;,,~.~,,_~~;.~~!,/~-,~I~,\~':~'~~'~~:!J~~;~'~-1~~~~,.i' g,1\fa~,8U~"IM9jIoun>_~_~ -' n. _..,"'....,-... did or _ (l,ilItI~..lloplacemontls..., . . j lor...,. ~...._hlglt~......,,: ".,ft!lIIllOIIy__~ . .m;._lIOO'f? .. (Tetla _'by'" ~ .. Have... sprinkler syst~ bean "...' . ,lull _ ..... of the -..gI ll. Does Ihero _10 be *""'"' -....Ie _tho lop of all...rago and tho ~ ~ o. Ant ...-bullding...... . '" ...: by a ...,........ _ . I. ,Its bIlnd _ and parlmatar areas, wha'" 8OOII8SIbI8? d. Are aU visible en8rior ooenii"ri8,~iaaaiast the ~af cold air? J #~EGTOR "Im mltll 9M'E ,,""',' , \.~ .:lY1Di~ HO.,",~:S'3S--. BVREAUFII..l;-..-.. .. . . _c ., ~ ":>h -~~:lr~.. . ~';"Y. .t'" ~'_ ~~"..~~."'~'4\ ~->"\:~~' en", ~""1." ".....2 - ,'" ,,~//I~~{ ;, lC:\;;o:J~ ,". ',./ "':,',' ,~;::f~if"'/4,y' 0': AEP.OFIT OF INSPECTION ../ '1.. ",_~$yaars) ~/ ./ \'-- :1-L ,.lilt- ~ t--= ';, 2. CONI1lOL VAl-vES a. .ke Itll''''''''''''"' syslam malnoontrol_ and all CIlhar _In ... appropriaIa open or oioS8d position, b. Are all control valves sealed or supervised. in the open position? 3. WA'l1!R SUPPLIES '1 a, Water supply source? CiIy&-.:Q. .ft. \< \; - , Watarflow Tool R_ Mado During ,ThIs "...".~.., j"L!!:.' 1<6l~;""'=~ I ~~~"'i'i9 I 4. TANKS. PUMPS. FIRE DEPT. CONNECTIONS a. Do fire pumps, gravity, surface or pressure tanks appear to be ,in good external condition? b. Are gravity, surface and pressure tanks at the proper pressure and/or water level"? 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 systems Maka & Modal ....1.:, P,P to. b. Are cold weather valves in the appropriate open or closed poSition" If closed, has piping been drained? c. Has the owner or owner's representative been advised that cold weather valves are not recommended by NFPA? d. Have all the antifreeze systems been tested? e. Dale antifreeze systems were tested f. The antifreeze tests indicate protection f.... s~tem~ ? ~ 4 g. Did alarm valves, waterflow alarm indicators and retards test satisfactorily? Control Valvae No. of Valvae I I I .1 I I CITY CONNECTION ' I T_~ ~~p..\ -1\1'" t~_ SECTIONAL [\ 1:>"'" . . J SYSTEM ALARM lINE ...."'m,..., P'ee ~\, <>." - SG45S0.A2-1 Typo 1''''''' 4:1,1:" ""'4' C1::V e.\: I ( !UI"} .. Batora tr...~ ~C\. 1~ Vas No :? ~ X/ ./ ./ GraVity Tank - ....-.. After T?"i -- Pressure ,--. l.f9 F_L.I Valva __ SUpervision $Ign\\ Open 11.... IIQw? taslad?~ Oparatkmal ~? Vas No y"". No Yes No Suovd. ?\ V.. No J J ./ ~ ~ I ../ ., "of $i ~ :, .;L ;'r \/ . ;; \.... ./ ;/ ./' ./ ./ ~/ v if y ~W"~ Pressure Fire Pump & Tani' N~ · :f\ Pressure Are Pump & City Pressure Fire Pump & Pond . Test .1'lpI>'. Looatlon SIze 'Taaf Pioe Statio '........"'" Ilefora SIaIk: ~~re After - Pressure ""'. 'OJ"...' -.... Yes N.A.:I; No. \./ L/ \"'/h}t=f\ I - . ,/ . 1;/ -- 5 temperature INSURANCE BUREAU COPY :f:NotAppllcable -Explain (No) Answers on Back of Sheet :i1: ~~,- '. ~t~~ORT NO............ .... """""/~ 3~ I~:<ci~ . REPQRT Of H\lSPECTfON ;. ., hE . lI'-l; l..ts-s c"'.oU" cL~e ..~~';~,,: ' .J :......;~l~&~l4,.~Q~. . -,tripW- '-" ~~t"'-(.l , . . .b.:~~:~~ pt>>Ssurellnd.p~_~~~:~J'. '.c: ,t;:)Ut;th8alr"':......r_....'~~Oril~ d. Were aU low, pofntsdrBined ~-tNiik~"'-llo,,' e. Old ~.quIck oper1lng dev~ _ satisf_rily? f. DicI:atl:.*"",,dfy vatyes opera.satilf8ctority'dUri"l1:thiS ...",","~'''',,? g. 00 dry valves ~r to be protectedfrorn:freezil1g') h. Is the dry valve hOLse heated? , ~~~~ BUREAU FilE . NO...... 7. SPECIAL 8VSTElIS a. No. of systems Type , b. Were valves testedasrequited? c. DId_attheat ""0'"-," ~"rr~~.-Jfn'_~ jl.Jli!l~~f~""""~l ..tI.. He8tResponsiveOevices:-tyr"', '.- \. type'otlesl. ValvaNo, 1......2......3....;.4,. ....5... ..6...... Valve. No, Valve No, 1......2......3......4......-5......6..... ValvaNo, ValveN,-.. 1......2......3......4.....;5......6...... Valve No, AUX~:; ~:ipmenl: No. L T 2.. .. 3~;. ~^f~it . B,6.tti'el~ ~<..t:, Locetloli l<. 'lP.1-N . . T..lresults Ill.t')~tl q.. 1"" Lol.., \2!>. D 1\11\"'" c~) ~ke & ~j "-11:l. ., ~ - ~,. '! "t' . !: - 'r" 11/ 1.....- 1./ .--T'.iT 1......2... 1......2... 1. .-....2... 1.,.... .2 SY'SiE1"\ ..3......4......5.. ...6...... ..3......4......5......6...... ..3......4......5... ..6.. . ..3.. ...,.4..... .5... ..6. , ~1-l1"T Cl-I'- \OA'S f'lR t/..\:;crR,<. ": <- ;~ , 8. ALARMS a. Did the water motors and QQAg operate dUl'ing testinr'') b.Oid_the electric alarms ope~te~Uling testinr'" c.Oid the supervisory a18f'tT!S,Qp&i'ateduring .~ng? 9. SI'Iltlf!<lERS -I'IPlNG.. . . . e. t1ci Sp-"'" ~liY !l/>IllIOt lObe ...good e~melo<mditiOt\? b. I?o .sprinklers'.~. _appnrtO_be".-free_ot oqri'oskm~ 'pa!ht, IJf .~ing.ancivisjbt8 ,obStructions? c. Are extra splinklerasvailable or:l-thep,.rIllses? d. Does the exteoorconditionOf piplrig, drain va\\tes, cheCk valves, hangers, pressure gauges, open sprinklers and strainers appaar to be satisfactOry" e. Does the hand hose on the sprinkler system appear to be In satisfactory condition? 10. EXI'LANATION OF "NO" ANSWERS (For sections lB thru 9): Dl'.I tc~Td-..""-N .~O()U IHI"Irt:::f<- OK FLOW .~ ..(" " ~"'~ ^I'( "'F~:rKIc:.., Ves N.A.t No' v ./ if ~ .\,t'.. V ./ V - , ::'t\:\\l \ ?- Ul " "'10\ U 1"" 1- ,.. .~jl.~~~~'Nli~~.:~~~E~,l~r:~~~oI>JtH~~VEV: ~.t~ ,-' ;:c,,()...~~... ~\~ULO ~... "'J;PT ""T"" fV\;.!I.:t'\lI\"'~ 0 I- I~' ~1:.t.C>W "r-r<;; 1~"Lt:~ k~"-~ ~l!.~ ~f~,~~~"'"R' ~ Tht;.. ~c.1\.L.L 1..1":5\ ON'TJ...i<. \/""' U ;"1 '-+,...-i.::; - b{,.. . ::.liol.\LU 1)0 A... Y ::>.....R\J6'! 12. ADJUSTMENTS OR CORRECTIONS MADE: , ./ . , ~ . 13. LIST CHANGES IN TNE OCCUPANCY HAZMID OR FIRE PROTECTlPN EQUIPMENT, AS ADVISED BV THE OWNER IN SECTION.1A: ./ 1.. INSPECTION AND SUGGESttD IMPROVE~~. \ --' +S~~jGNEil OWNER OR OWNER~~~? SIQnature of owner or owner's representative ~~. " .../ Date' I 0'" . \. DUPLICATE TO: STREFT CITY & STAT!:: ATT. SG4550R1-2 'jp :tNotApplicable "Explain (No) Answers on Back of Sheet INSURANCE BUREAU COPY "tileD/Fire &: / SilllplexGri..e" Security ~ DRY PIPE VALVE TRIP TEST REPORT FOR-rhe. \N; L~s ~oLF c::A..u.e STREET?'\~I WiLCss R'.r\~E. c::r. N~.. DATE OF TRIP TEST ~ - I (C.. _,,~ INSPECTION NO. CONTRACT NO. DAY WORK NO. c, f)' 'S'~ INSPECTOR NOTE: BEFORE ANY DRY PIPE VALVE IS TRIP TESTED. THE WATER SUPPLY LINE IT SHOULD THOROUGHLY FWSHED. THE TWO INCH DRAIN BELOW THE VALVE SHOULD BE OPENED WIDE, AND WATER AT FULL PRESSURE SHOULD BE 01 HAR13ED LONQ ENOUGH TO CLEAR THE PIPE OF ANY ACCUMULATION OF SCALE OR FOREIGN MATERIAL IF TI-lERE IS A HYDRANT ON THE SUPPLY LINE, THIS HYDRANT SHOULD BE FWSHED BEFORE THE T\NO INCH DRAIN IS OPENED. THE nRIP VAl VI;: ON THE DRY PIPE VALVE SHOULD BE CHECKED BEFORE TRIPPING THE DRY PIPE VALVE. TO SEE THAT IT laiN OPERATING CONomON. DRY PIPE VALVES SYSTEM NO. ( I INCH I I '(APPROX) I \...Bo- 64 J 1- 7{<::> -of/ I 4 U. LBsl ,,4 LBSI ~"-;r:.-rV I Y I ~ LBsl G:. '-i LBSI MIN'/O sEel MIN _ sEel I I I ~q~ I~ t (/ )\ - -SYSTEM NO. <l\\~\)-I SYSTEM NO. ( 71 TYPE AND MODEL J~ .AIR PRESSURE IN UPPER CHAMBER .~ LBS QUICK OPENING DEVICE TRIPPED AT SEC. . LBS PERFORMANCE J ~ QUICK OPENING DEVICE LEFT IN SERVICE / - . . . . ~D CONTROL OPEN _AND SEA~EO? .__ _ VALVE SERIAL NUMBER MANUFACTURER (NAME) VALVE MODEL VALVE SIZE CONTROLLING SPRINKLERS I (LOCATION) I (NUMBER) DATE LAST TRIP TESTED? DATE lAST OPERATED? lAIR I WATER SIZE AND.LOCATlON OF TEST VALVE PRESSURE BEFORE TEST WAS GATe VALve BE1.OW DAY VALVE OPEN wtDE AT TEST? (IF NOT. HOW MANY TURNS?) I AIR PRESSURE I WATER PRESSURE I TIME IF SYSTEM FLOODEO, LIST 11ME WATER REACHED TEST OPENING VALVE TRIPPED AT I I I INTERIOR Of' BODVI I MOVING PARTS I RUBBER FACING I SEATS RESET? DID ALARMS OPERATE AT TRIP TEST? PERFORMANCE VALVE CONDITION ALL LOW POINT DRAINS BLOWN OUT? WATER CONTROL VALve LEFT OPEN AND SEALED? ALARM __... ......._ VALVE LEFT OPEN ANO SEALED? QUICt< OPENING DEVICES DEVICE SERIAL NUMBER MANUFACTURER (NAME) LIST ANY UNSATISFACTORY CONDITIONS: REMARKS SG 4274 R2 ~EM ~ ~o~ 4 , A't'T. c;. SYSTEM NO. ( SYSTEM NO. ( SYSTEM NO. ( INCH INCH INCH (APPROX) (APPROX) (APPFlOX) LBS LBS LBS LBS LBS LBS MIN MIN LBS LBS SEe SEe LBS LBS LBS SEe SEe LBS SEe SEe MIN MIN MIN MIN SYSTEM NO. ( SYSTEM NO. ( SEe LBS LBS LBS LBS SEe LBS SEe LBS t'l*lIFmf1~ ./.........",...,."." /Secunty. . . REPORT OF INSPECTION perNFPA 13 & 25 r--J~. r W~ ~-... ..... .... ..:r-. ...._~...~. ............... ...... .,i.,~ ~..;.,. '. ,",' .,.. ....... ..N\~ I .' . ZIP <~~~. 1. GENERAL A. (To be.answered by thebwner or OWner's representative) a~ Have. there been any l;hangeS in the occQpancy classification, machinery or operations since the last inspection? b. Halle there been any Chahges or repairs to the fire pr018illtonsystems since the last inspection? c. If a fire has occurred since the last inspection, have all clilmaged sprinkler system components been replaced? d. Has the piping in all.dry systems been checked for proper pitch within the past five years? Date last checked .... e. Has the piping In all systems been checIiecI for obstructive malenals? Date I8stcheCked (checking is recommended alleast every 5 years) . f. H'aveh!l1ltt~:_.~'i6 the1rO;'~ ~h the use:~ hose ~ or-fJM'~witt1iA the.PIisl12 . ",......"'? g. Are gravity, surface or pressure tanks protected from freezing? h. Are any of the sprinklers 50ye~ Old or older? (testing and/or replacement is recommended for such sprinl<lers) Are. any extra high temperature solder sprinklers regularly exposed to temperatures near 3000F? B. (To be answered by the inspector) a. Have the sprinkler systems been extended to all visible areas of the building? b. Does there appear to be proper clearance between the top of all storage and the sprinkler deflector? c. Are the building areas protected by a wet system, heated, including its blind attics and perimeter areas, where accessible? d. Are all visible exterior ooeninaSDrotected aaainst the entrance of cold air? ..,PECTION REPORT NO......~........:.........................................:::.................. CONFERRED WITH REPORT TO~'ft. \1\,\ \ lc ~'\~ STREET -=t ~. ~f. '~'~~f}! CITY & STA~ r-~~. L JXlt<.E . ATT .. . , . BUlLOING Ot;t~ATI INSPECT . SGOFACE. DATE :~~~~~~ BUREAU FILE ................................... .~).......;.......,...,..._...,......=.\+,.............................. ~;1 OF2 PE~EJ?,$A.~)= A. .~~.,..,.~..;.,:>... . PHONE NQ'3ID'"'5c;cc .~'t -Q.t;." .,. -.,. . ',.,."".... yeS. N-~.~ I No' ~. V' (Checking is .............ded at least every 5 years) .- ~/ r/ ./ ,Y/ ,/ \/ V V 1/ 2. CONTROL VALVES a. Are all sprinkler system main control valves and all other valveS in the appropriate open or closed position? b. Are all control valves sealed or supervised in the open position? Control Valves No. of Valves CITY CONNECTION '!IIIN< ~\'\ PUMPE. -= .. - ~ SECTIONAL Q - SYSTEM ALARM LINE \ ~ I Type () "':V. ).F= \1 F\/ f'J Gill 3. WATER SUPPLIES 1"'r-', /\ a.. ,,. a. Water supply source? City Tl'\. \ QQ. ~ Waterflow Test ReSults Made During This Inspection Test Size Static Pipe Test Pressure' Located Pipe ~e ~C\"'5~~. ~\I I'! 4. TANKS, PUMPS, FIRE DEPT. CONNECTIONS a. Do fire pumps, gravity. surface or pressure tanks appear to be in good external condition? b. Are gravity, surface and pressure tanks at the proper pressure and/or water levels? c. Are fire dept. connections in satisfactory condition, couplings free, caps or plugs in place and check valves tight? d. Are fire dept. connections visible and accessible? 5. WET SYSTEMS a. No. of systems b. Are cold weather valves in the appropriate open or closed position? If closed, has piping been drained? c. Has the owner or owner'srepresentative been advised that cold weather valves are not recommended by NFPA? d. Have all the antifreeze systems been tested? e. Date antifreeze systems were tested f. The antifreeze tests indicate protection tn' system 1 ? 3 4 g. Did alarm valves, waterflow alarm indicators and retards test satisfactorily? l~r:~,! ~. \ ':\~~, ~\I .c;::~ Easily Accessible Yes. No \/ J ~/ \/ V \/ Signs Yes No \/ \/ \j V V Gravity Tank-----hJ..A FloW Pre$sure 1.)11 Static Pressure After C...:~ 4~ (. ~. J Make & Model illY .p ~ D f W/lNF\\ I SG4550.Rl.l (2/05) INSURANCE BUREAU COpy v Valve Secured? Supervision Open If yes, how? 'Sealed?) Operational Locked?) Yes No Yes. No Supvd.?) Yes No ./ ./ $~ ./ \./ ./ \/ ./ t/ V j ./ t/ l/ ~ . ::tir; l\ 1./ t./ 1/ Pressure Fire Pump & Tanl< NA Pressure Fire Pump & City Pressure Fire Pump & Ponli Tes\!. Size Static Static Pipe Test Pressure Flow Pressure Location Pipe Before Pressu re After Yes 1./ N.A,:I: ,/ V No' 1/ V L/ 5 temperature tNot Applicable 'Explain (No) Answers on Back of Sheet 2 tl./CO!Fire &./ Simp/exllrinne// Security DRY PIPE VALVE TRIP TEST REPORT FOR Thl! \N'\ L.D-:S ~ <> LF- GL.",e STREET 3 \ S I W I L~'S R/~~c;;..e.. c:::T ,,-,\tIC CITY ~~6A LA ~ STATE M t\\ CONTRACT NO. DATE OF TRIP TEST ~ - :J~ L INSPEC;OR --"v~ ~A\IJ^ DAY WORK NO. NOTE: BEFORE ANY DRY PIPE VALVE IS TRIP TESTED, THE WATER SUPPLY LINE TO IT~HOULD :;:~~ROUGHLY FWSHED. THE TWO INCH DRAIN BELOW THE VALVE SHOULD BE OPENED WIDE, AND WATER AT FULL PRESSURE SHOULD BE DISCHARGED LONG ENOUGH TO CLEAR THE PIPE OF ANY ACCUMULATION OF SCALE OR FOREIGN MATERIAL IF THERE IS A HYDRANT ON THE SUPPLY LINE, THIS HYDRANT SHOULD BE FWSHED BEFORE THE TWO INCH DRAIN IS OPENED. THE DRIP VALVE ON THE DRY PIPE VALVE SHOULD BE CHECKED BEFORE TRIPPING THE DRY PIPE VALVE. TO SEE THAT IT IS IN OPERATING CONDITION. DRY PIPE VALVES VALVE SERIAL NUMBER MANUFACTURER (NAME) VALVE MODEL VALVE SIZE CONTROLLING SPRINKLERS (LOCATION) (NUMBER) DATE LAST TRIP TESTED? DATE LAST OPERATED? I AIR PRESSURE BEFORE TEST I WATER SIZE AND LOCATION OF TEST VALVE WAS GATE VALVE BELOW DRY VALVE OPEN WIDE AT TEST? (IF NOT, HOW MANY TURNS?) I AIR PRESSURE VALVE TRIPPED AT I WATER PRESSURE I TIME IF SYSTEM FLOODED, LIST TIME WATER REACHED TEST OPENING PERFORMANCE INTERIOR OF BODY MOVING PARTS VALVE CONDITION RUBBER FACING SEATS RESET? DID ALARMS OPERATE AT TRIP TEST? ALL LOW POINT DRAINS BLOWN OUT? WATER CONTROL VALVE LEFT OPEN AND SEALED? ALARM CONTROL VALVE LEFT OPEN AND SEALED? QUICK OPENING DEVICES DEVICE SERIAL NUMBER MANUFACTURER (NAME) TYPE AND MODEL AIR PRESSURE IN UPPER CHAMBER QUICK OPENING DEVICE TRIPPED AT PERFORMANCE QUICK OPENING DEVICE LEFT IN SERVICE AND CONTROL OPEN AND SEALED? LIST ANY UNSATISFACTORY CONDITIONS: REMARKS G 4?74 R? INSPECTION NO. '-} LJ6 ,)5,~~ SYSTEM NO. ( SYSTEM NO. ( SYSTEM NO. ( SYSTEM NO. ( GF-(V\ f - ~ ()~ ~ INCH A'TT, c... INCH INCH INCH (APPROX) (APPROX) (APPROX) (APPROX) ~ ~ \0 - <,,-><:::," '?-. - \ 0 - o~ 1..1 ~ LBS G:. :J LBS ~ II A.I'SP\Sf... LBS LBS LBS LBS LBS LBS 0 LBS ~~ LBS ~ MIN 0 SEC MIN _ SEC c;. <::> o1.j II \~ t) "IE..~ 1/ - \\ LBS LBS LBS LBS LBS LBS SEC MIN SEC MIN SEC MIN SEC MIN SEC MIN SEC MIN SYSTE~ NO. I\\..\t:\ )_ / /' ;t~ SYSTEM NO. ( SYSTEM NO. ( SYSTEM NO. ( LBS LBS LBS LBS LBS SEC LBS SEC LBS SEC LBS " '~1 /' ~//i"CO/Fire ~ /S;_~..." Security ~ - :r~ . oG,. ~" INS~ECTlON REPORT ... RepORT OF INSPECTION " > NO............... ....".,.. .... .." ..., . ~l" PEBNFPA13.i:,,2S'.i:..('J "~:" .. " .';;' ..r-i: "'\\fl'\"'S;.:~.t.;f;4~f' ,':, ,!;''';;,~:~ " '. ,;"r'<";"~;';';'~i'~,'.~~)fJ\:.. .i'~~."".. . ~: ...~:)>P.:..~.'~~',':-',',"~;;;:yE,'.'2\~tt5'...hs~i.~':.,';,....., '..'..p' ~;:.;;". '~b'ls~. air ~r8a~Pri:tnIOgwat8r Ievel&nonna/? Ii; c.Did theair'~compntssor.~..",,;. iatlsfactorily? ';~ Ct. ,Were. all tow pOints. drained-during this inspeCtiOn? 8.' DId all. quick opening devices operatesa,:..I..~,"rily? f. Did all the dry valves operate satisfactorily during this inspection? g. Do dry valves appear to be protected from freezing? h. .Is the dry valve house heated? ~;~y~~~8~~ BUREAU FILE,,,,,,,, .... NO. ,~'+..",....."_........\."....."...~,.~...,,.,..... .., (> . '.'sJf~'OF-..2':Y . d/'",,,';,:;;':,..,....'.'...'........ -Vi es,,;<~...~:~;r ;\;':<~_-::";.:<'f.\' _. .... ",..::' ",'.'::' "..' '.~'-' .V'\........ ". V -------- ,,/ \I V v .t.... 7. SPECIAL SYSTEMS a. No. of systems 0 Typ" b. Were valves tested as required? d:..t.:e~pe~81~:~~~~~~=r1~~.;~~; '~( '1 t \, " r , ..,' ,\'""'.. I '. '1~' .~'I Heat Responsive Devices: Type Type of test Valve Nr 1 . . . . .. 2 .. .. . . 3 . . . . . . 4 . . . . . . 5 . . . . . . 6 . .. .. . Valve N^ 1 . . . . . . 2 . . . . . . 3 .. . . .. 4 . . . . . . 5 . . . .. . 6 ... . . . . Valve Nr 1 . . . . .. 2. . . . .. 3 . . . . .. 4 . . .. . . 5 . . . . . . 6 . . .. .. Valve N^ 1 .. .. . . 2 . . . ... . 3 .. . . . . 4 . . . . . . 5 . . . .. . 6 . . . . . . Valve Nr. 1 . . . . . . 2 .. .. .. 3 . . . . .. 4 . ., .. . 5 . . . . .. 6 . . .. .. Valve N'" 1 .. . . . . 2 . . . .. . 3 .. . . . . 4 . . . . . . 5 .. ,... . 6 . . . . . . AU;:; ~~iPment: NO.1. .1.2.... .~\~~~.4j.jA~t.~.... R~~e~.,\\ Ho~\)' .2..... .3..... .4..... .5.. ....6...... Location K \ \" ~1: N - E:.. Test results">> M~ E R ~ ~ \} f'l...DW w):.. NT Tn r'1'\ t-.lt: L _ H fA , ~,~ ~c>,:s \i \IT 0 f". ~ A'S 0 ~ ): l...€.<."'\ftJG- Make & Model ~)~, ..,,1,. , :-:;-:, " , '"'~I. 8. ALARMS a. Old the water motors and gong operate during testing? b. Did the electric. alarms operate during testing? c.Did the S4pervisory.a/arms operate during testhig? ,.,$PRlN~..~$ ",'PIPIN() .a.Oosprinklersgenerally appear to be. in good external condition? b. Do sprinklers generally appear to be free of corrosion, paint, or loading and visible obstructions? c. Are extra sprinklers available on the premises? d. Does the exterior condition of piping, drain valves, check valves, hangers, pressure gauges, open sprinklers and strainers appear to be satisfactory? e. Does the hand hose on the sprinkler system appear to be in satisfactory condition? Yes \/ 1/ ~ No' J V- I/' 1/ 1/ 10.gP~NA~~~.~~~S~ER~~~ns~f)\pj:~ A~~ F LoW ~:~N~L~ D', D ~o To, ~~N'c..L- . 0'"" \ \knt-i:~ 0'"' rl...OW L;D )\)0 J -S tHn o,.:t: ~ ok ~<;;'K~C'! i ~,lTh~~~:~~~~T~~l':t~~~Yt ~ \..10 \ ~ ":) Heu.. ~ "'-t.t: {- '.5 10 H.t\(,o \:::. I' ('\ . IV \ IN.' r>J,:L-O W ~l"""" ) N K 1:. 1'\ "'" J ." "3. 'T".h~lq;,~ k'~ Io\~_\ 'QR~ '-~O:SE..l I N_ \,,~ K A.~\:. l"lt;f\.\-r ~ HctALf\ t'~).l..Cy \ \-\e.Ac ~OW N --rr..RO\..\~ \1 ~E.; Li N 6 12. ADJUSTMENTS OR CORRECTIONS MADE: 4' ./ /' 13. LIST CHANGES IN THE OCCUPANCY HAZARD OR FIRE PROTECTION EQUIPMENT, AS ADVISED BY THIO OWNER IN SECTION 1A: /' ./ / ..", . 14. INSPECTION AND SUGGESTED.IMPROVI\MJNTS WE"~.DI~ED.WIT;THE Urt~SIGNED OWNER OR OWNE~ RE~.~!'NTATIV~ Signature of owner or owner's representativ~ 1AJ~ '::h r v ~ ...... _..IC \.-A(.... Date. ~ ~ .. I J? ..-.cJ.~ .~.I .. DUPLICATE TO' STREET CITY & STATF ATT SG4550R2-2 (04-05) ZIP tNot Applicable 'Explain (No) Answers on Back of Sheet INSURANCE BUREAU COPY ~ -., . -----..-- .~._...-_.._------......,----