2750 Sibley Memorial Hwy - Contractor's Material & Test CertificateContractor's Material and Test Certificate for Aboveground 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 name
L,vS't S • -6 Cv
Date
° 1 - R U
Property address `` y
/
C �U�F , j 1t (."0( ia, ‘1
Plans
LJ1
Accepted by approving authorities (names)
■
Address S
Installation conforms to accepted plans Yes I 1 No
Equipment used is approved g Yes I 1 No
If no, explain deviations
Instructions
Has person In charge of fire equipment been instructed as Iii Yes I 1 No
to location of control valves and care and maintenance
of this new equipment?
If no, explain
Have copies of the following been left on the premises? Yes 1 1 No
1. System components instructions Yes 1 1 No
2. Care and maintenance instructions Yes 1 1 No
3:. N 'PA 25 Yes 1 _I No
/�
Location of
system
Supplies buildings
Sprinklers
Make
Model
Year of
manufacture
.. Orifice
' size
Quantity
Temperature
rating
&
?oI)
ISS
ok
1 �'
PZAs' 511'1
'-1' ` a
-- - -1I
z. 011
x�
In
1.
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Si?
'SS'
i,5 "
-,1430°
c� ''
RA ► `t J'1
-
AA-60u,-
i o s r �
1 e I 1
�'� z.
5
Pipe and
fittings
a ra
Type of pipe ..
., r
Type of fittings 1
w1
A
Alarm
vlae or
flow
indicator
Alarm device
Maximum time to operate
through test connection
type
Make
Model
Minutes
Seconds
G .` 1 • .. C (
Di"
"PS-
0
OA
tOcx
IL,s S•., :l.t, Sr,„os..
Dry pipe
operating
test
-- iv
Dr�
Q. O. D.
Make
Model
Serial no.
Make
Model
Serial no.
Time to trip
through test
connections
Water
pressure
Air
pressure
Trip point
air pressure
Time water
reached
test outlet
Alarm
operated
properly
Minutes
Seconds
psi
psi
psi
Minutes
Seconds
Yes
No
Without
Q.O.D.
1 8
C�
q
Q
_
act
Ida
X
With
Q.O.D.
If no explain
Hydraulic
data
nameplate
Nameplate provided
1 Na
If no, explain
[5? Yes 1
Remarks
Date left in service with all control valves open
•
Signatures
Name of sprinkler contractor
Tests witnessed by
For property owner (signed)
Title
`
t'
Date ,
For sprinkler contractgi' (signed)
..: _.
Title
Date
—
Additional explanations and notes
Deluge and
pon
valves
Operation
I I Pneumatic 1 I Electric I I Hydraulic
Piping supervised I I Yes I 1 No
Detecting media supervised C] Yes I I No
Does valve operate from the manual trip, remote, or both I I Yes 1 I No
control stations?
Is there an accessible facility In each circuit
for testing?
I IYes I INo
If no, explain
Make
Model
Does each circuit operate
supervision loss alarm?
Does each circuit operate
valve release?
Maximum time to
operate release
Yes
No
Yes
No
Minutes
Seconds
Pressure
redwing
valve test
Location
and floor
Make and
model
Setting
Static pressure
Residual pressure
(flowing)
Flow rate
Inlet (psi)
Outlet (psi)
Inlet (psi)
Outlet (psi)
Flow (gpm)
Test
description
HydrOatatiC; Hydrostatic tests shall be made at not less than 200 psi (13.6 bar) for 2 hours or 50 psi (3.4 bar)
above static pressure in excess of 150 psi (10.2 bar) for 2 hours. Differential dry - pipe valve clappers shall be left
open during the test to prevent damage. All aboveground piping leakage shall be stopped.
Pneumatic Establish 40 psi (2.7 bar) air pressure and measure drop, which shall not exceed 11/2 psi (0.1 bar)
in 24 hours. Test pressure tanks at normal water level and air pressure and measure air pressure drop, which shall
not exceed 11/2 psi (0.1 bar) in 24 hours.
Tests
All piping hydrostatically tested at C).- psi (.. bar) for hours
If no, state reason
..
Dry piping pneumatically tested J(1' Yes 1 1 No
Equipment operates properly Yes I I 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 I I No
Drain
test
Reading of gauge located near water
supply test connection: psi (, bar)
Residual pressure with valve in test
connection open wide: psi (____ bar)
Underground mains and lead in connections to system risers flushed before connection
to sprinkler piping
Verified by copy of the U Form No. 85B 35 Yes 1 I No
Flushed by installer of underground
sprinkler piping I' Yes I 1 No
made
Other Explain
If powder - driven fasteners are used in concrete, has I I Yes j ' No
representative sample testing be satisfactorily
completed?
If no explain
Blank testing
gaskets
Number used
0
Locations
Number removed
0
Welding
Welding piping > Yes I 1 No
If yes.. .
Do you certify as the sprinkler contractor that welding procedures comply isi Yes I I No
with the requirements of at least AWS B2.1?
Do you certify that the welding was performed by welders qualified in
compliance with the requirements of at feast AWS B2.1? J i Yes I I No
Do you certify that the welding was carried out in compliance with a documented
quality control procedure to ensure that all discs are retrieved, that openings
in piping are smooth, that slag and other welding residue are removed, and that w Yes I I No
the internal diameters of piping are not penetrated?
Cutouts
(discs)
Do you certify that you have a control feature to ensure that
all cutouts (discs) are retrieved? Yes I I No