21727 76TH AVE W (2)PREVENTION
�7 (A -A /I t' w FIRE
INSPECTION REPORT
'JOHOMISHc6.- ts�rl"iihk* 7` i s, and 12425 Meridian AveS, I
a I I lIt, 17 _ EDMONDS
-e Teri-a�e` '- J.-
A, , 0 d Everett, WA 98t?0$i,*4 0 BRIER
9 untlak
FIRE - 0 MOUNTLAKE TERRACE
Phone (425) 5�1-1200 0 UNINCORPORATED
DISTR T www.FireDistrict"*]'.org Pax (425),'551-1272
r-FREQUENCY STATION & SHIF")
LOCATION: 4,
21727 76th Avenue W Bdq GSD26 fivinual 20-A
SCHEDULED
XIDATEDUE �Nuv2f)13
BUSINESS NAME: Warran MccliGal CcnLcr PHONE:
MAILING
ADDRESS:
2-1727 7fith AveriucI4, Bldg, bdrymrdbii. 9,302L
BUSINESS OWNER:
NA/rilfF-41
HOME PHONE:
EMERGENCY-1:
x-
ACNN A Mithew
HOME PHONE: 4',j557bd76j)
CURRENT
�;IKEY ACCESS-2:,
HOME PHONE:
57�,F-700
CIT y YES NO'
BUSINESS -1 El
E
EMAIL:
LICENSE
PERSON CONTACTE D:
INITIAL INSPECTION DATE
NAME OF INSPECTOR:
t + I
FIRE SYSTEMS;
AS' 11112 FA 4107-i-t FE 4 1 1
111/12-
HAZARDS FOUND AND LOCATIONS / COMMUNICAfIONS
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I AGREE CORIR-ECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
lst RE -INSPECTION__
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTED TO:
FINAL RE-INSPECTIO
DATE DUE:
PERSON
VIOLATIONS
CITED -
PERSON
PERSOINi
CONTACTED:
INSPECTOR:
CONTACTED:
CONTACTED:
INSPECTOR:
DATE:
INSPECTOR:
DATE:
E:
VIOLATIONS
V� IONS i
PRE -CITATION
CITATION ISSUED
1 5
15
LETTER SENT
NUMBER:
2
6
11
2
6
DATE:
CODE
SECTION:
5
RETURN RECEIPT
6
3
7
3
7
RECEIVED
DISPOSITION:
7
4
18
I
8
1 1
DATE:
\1 LETTER NEEDED [] YES N 0
LETTER NEEDED [] YES El NO
1
1
8
FIRE DEPARTMENT COPY
IL
'Fire Protection Contractors since 1930
VIKING AUTOMATIC SPRINKLER COMPANY 3434 First A". So., Seattle, WA 98134,206,622.4656
WA.: VI-KI-NA-S373NT LEVEL N 602 California Way, Longview, WA 98632,360,425.7620
.4
Ncir
Fire Sprinkler Inspection Report Page:lof2
REPORTTO: JOB NO. 42 DATE:
STREET: 2/77-7 .24 A,1,4F 414'5 1-' BLDG./ LOCATION: 1#1 V14Z
CITY/STATE: INSPECTOR:
1.GENERAL
a. Is the building occupied ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Is occupancy the same as previous Inspection ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
c. Are all systems In service ?
1 , I � I . . . . . . . . . . . . . . . . . . . .
d. Are all fire protection systems the same as last Inspection ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
a. Is the building completely sprinklered ?- - - 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .
f. Are all new additions and building changes properly protected ? . . . . . . . . . . . . . . . . . . . . . . . . . . .
g. all stock or storage properly below sprin�ll�r ploln"g, ...... . . . . . . . . . . . . . .
h. Was property free of fires since last Inspection ? (Explain any fire on Page 2) . . . . . . . . . . . . . . . . . ..
1. In areas protected by wet systems, Is building properly heated, I.e.: blind attics, perimeter areas, and are all exterior openings protected against the cold
2. CONTROL VALVES (See Section 17)
a. Are all sprinkler system main control valves open ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Are all other control valves In proper position ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I
c, Are .11 control valve. In good condition and sealed or supervised ? . . . . . .. . . . . . . . . . . . . . . . . . . . .
3. WATER SUPPLIES (See Section 18)
a. Was a water flow test preformed and were the results satisfactory ? . . . . . . . . . . . . . . . . . . . . . . . . . .
4. TANKS, PUMPS, & FIRE DEPARTMENT CONNECTIONS
a. Are fire pumps, gravity tanks, resevoirs and pressur a tanks In good condition and properly maintained ? . . . . ?w - - - - - -
b. Are Fire Department Connections In satisfactory condition, couplings free, caps In place and check valves tight I . . . . . .
5. WET SYSTEMS (See Section 13)
a. Are cold weather valves open or closed as necessary ? . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .
b. Have antifreeze systems been tested and left In satisfactory condition ? Temp. ? . . . . . . . . . . . . . . . . . .
c. Are alarm valves, waterflow Indicators and retard chambers In satisfactory condition ? . . . . . . . . . . . . . . . . . . . .
6. DRY SYSTEMS (See Section 14)
a. Are dry vaIv.e(s)'In service and In good condition ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Are pressure and priming water levels normal ? . . . . . ... . . . . . .. . . . . . . . . . . . . .
c. Is air compressor In good condition ? - - - ---- - - - - . . . . . ... . ... . . . . . . . . . . . . . . . .
d. Were low points drained during fall and winter Inspections ? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
a. Are Oulck- opening devices In service ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
f. Has piping been checked for stoppage within the past ten (10) years ? . . . . . . ... . . . . . . . . . . . . . . . . .
9. Has piping been checked for proper pitch within the past five (5) years ? . . . . . . . . . . . . ... . . . . . . . . .
h. Have dry valves been trip tested satisfactorily as required ? . . . . . . . . . ... . . . . . . . . . . . . . . . . . .
1. Are dry valves adequately protected from freezing ? . . . . . . . . . ... . . . . . . . . . . . . . 7 . . 1 _
1. Are valve house and heater conditions satisfactory ? . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . .
7. SPECIAL SYSTEMS (See Section 16)
a. Were valves tested as required ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Were all heat -responsive systems tested and were the results satisfactory ? . . . . ... . . . . . . . . . . . . . . . . .
c. Were supervisory features tested and were the results satisfactory ? . . . . . . . . . . . . . . . . . . . . . . . .
&ALARMS
a. Is the water motor and gong test satisfactory ? - - - - - -
. . . . . . . . . . . . . . . . . . . . .
b. Is the electric alarm test satisfactory ? - - - - - - - - - - . . . . . . . ... . . . . . . .
c. Is the supervisory alarm service test satisfactory ? Monitoring Co- Ph.:24� 2M Code: 9C,- W.17
9. SPRINKLERS - PIPING
a. Are all sprinkler heads In good condition, not obstructed and free from corrosion or loading ? . . . . . . . . . . ...
b. Are all sprinkler heads less than fifty (50) years old ? Head Manufacturer: e".' 1000 Date of head : ZIM
WHITE: VIKING COPY YELLOW: INVOICE COPY PINK: FIRE DEPARI!�IENT COW GOLD: BUILDING COPY
L%
LAJ'
Fire Protection Contractors since 1930
VIKING AUTOMATIC SPRINKLER COMPANY' 3434 Riat Am- Sa, Seaft WA 98134, 206. 622. 4656
WA: Vl1-KPNA-S373NT LEVEL /it 612 Caffamin Wgy, Longview, WA 360.425.76W
I
Fire, Sprinkler Inspection' Report Page:202
9. SPRINKLER PIPING (Continued)
YES N.A.
kNA,
c. Are extra sprinkler heads readily available.? . . . . . . .. . . . . . - - - - - - - - - - -- --- - - --- -- - - - -
?
d. Is condition of piping, drain 4alves,,check valves, hangers, p open sprinklem,.and strainers 8-Iffictory
�101 I I � " z,�
e..Ari all sprinklers of properotemperature ratIngI7. ;0
f. Are portable fire extin u1shem In:jo�d'condftIon.?--
. . .... . . . . . . . . .
;.g
g. Is hand hose on sprinkler systems satisfactory ?
10 Date Dry System Piping last checked for stoppage .. . .. . .. . . . . . . . . . . . . . - - - - - - - - - - - - - - --
It. Date Dry System Piping last checked for proper pitch .. . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . .
12. Date Dry Pipe Valve last trip tested. -- - - - - - - - - - - - - - - - - - - - - - - . . . . . . .
50/
13. Wet systems: Number. Make Model Yese�
14. Dry Systems: Number: Make Model Year -
15. Accelerator: Make / Model Year:
16. Spitclal Systems: Number: Typ
Make Model Year: Condition
17. CONTROL VALVES
a. City Connection Control Valves . . . . . .
b.Tank Control Valves - - - - - - - - -
c. Pump Control Valves . . . . . . . . .
d. Sectional Control Valves . . . . . . . . .
e. System Control Valves,
NINE. �-
1 WATE
R FLOWTEST
a. Water Pressure Source :0 City, Dmink 0 Fire Pump, Water'Flow Test taken If not, reason:
Test Pipe Location Size Test Pipe Pressure Before Flow Pressure Pressure After
A7-. IZ�,
yv
79
29
X0
19. Explanation of any "No" answers:
20. Recent changes In building occupancy or fire protection equipment:
21. Adjustments or corrections made:
22. Desirabi mprovements:'.
23. Has building' owner/ representative been notified of any deficiency to the fire protection system? 0 Yes 0 No, Person notified:
It answer Is "No",explain-
24. Inspector's Signature:
VIKING
Witness (property owner / lessee) and date:
YELLOW: INVOICE COPY PINK: FIRE DEPARTMENT COPY GOLD: BUILDING COPY
p
Pire'Protection Contractors since 1930
VIKING AUTOMATIC SPRINKLER COMPANY 3434 First Ave. So., Seattle, WA 98134, 206.622.4656
WA: VI-KI-NA-S373NT LEVEL N 602 California Way, Longview, WA 98632,360,425.7620
Fire Sprinkler Inspection Report Page:. 1 of 2.
J
�J B N DATE:
-sm
AE06RT TO: 0 0.,
2/1. -e' e-
STREET: SLOG.1 LOCATION':-<' 0
:Z1
I STATE",:"
INSPECTOR:,
I.GENERAL, YES N.A. NOI
a. Is the building occupied ? . . . . ... . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2—C
b. Is occupancy the same as previous Inspection ? . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .
C. Are all systems In service ?
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
d. Are all fire protection systems the same as last 1680 Ion ? . . . . . . . . . . . . . . . . . . . . . . . . . . . I
a. Is the building completely sprinklered ? . . . . ... . . . . . . . . . . . . . . . . . . . . .
I. Are all now additions and building changes properly protected? .. . . . .
7 - - - - - - -
g. g—pr . . . . . . . . . . . . . . . . ... . .
Wall stock or store 0 operly below sprinkler, piping ? . . .
h. Was property free of fires since last Inspection ? (Explain any fire on Page 2) . . . . . 7 . . . . . . . . . . . . . . . . . . .
1. In areas protected by wet systems, Is building properly heated, I.e.: blind attics, perimeter areas, and are all exterior openings protected against the cold ?
2. CONTROL VALVES (See Secti on 17)
a. Are all sprinkler system main control valves open ? . . . . . . . . . . . . . . . . . . . . . . .
b. Are all other cont rol valves In proper position ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . .. . . 11
c..Are all control,valves In good condition and sealed ,:or supervised ? . . . . . . . . .
3. WATER SUPPLIES (See Section 18).
a. was a water flow test pief6rmed and'were'thi results -.'satisfactory
? . . . . . . . . .
C' j
4. TANKS.,PUMPS, & FIRE DEPARTMENT CONNE TIONS
a. Are fire pum �Ix
pal: gravity tanks, resavdirs and pressure tanks In good condition and,properly maintained ? .
b. Are Fire Department Connections In satisfactory condition, couplings free, caps In place and check valves tight ?.
5. WET SYSTEMS (See Section 13)
a. Are cold weather valves open or closed as necessary ? . . . . . . . . . . . . . . . . . . . . . . . . .
b. Have antifreeze systems been tested and.left, In, -satisfactory condition? Temp.? . . . . . . . . . . . . . .
c. Are alarm valves, water flow Indicators and retard chambers In satisfactory condition ? . . . . . . . . . . . . .. . . . .
6. DRY SYSTEMS (See Section 14)
a. Are dry valve(s) In service and In good condition ?
.. . . . . . . . . . . . . . . . . . . . . . . . .
b. Are pressure and priming Water levels normal ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .
�-.c.* Is air- compres�br-in,go6d-c�nditionl?,*-
d. Were low points drained during fall and winter Inspections T
I . 2 . . i . . . . . . . . . ...
a. Are dUlck-V�enlng devices In service ? . . . . . . . . . . . . . . . .
.t I. Has piping been checked for stoppage within t he past ton (10) years ? . . . . . .
. .. . . . . . . . . . . . . . . . .
g. Has piping been checked for proper pitc.h. within the past five (5) years ? . . . . . . . . . ... . .... . .
h. Have dry valves been trip tested latifictorily as required ? . . . . . . . . .. . . . ... . . . . . . . . .
1. Are dry valves adequately protected from freezing ? . . . . ..... . . . . . . . . . . . . . . . . . . . . .
1. Are valve house and heater conditions satisfactory ? . . . . . . . . . . . . . . . . . . . . .
.7. SPECIAL SYSTEMS jSee Section 16)
a. Were valv
b Were all,peal�respimsivi a tern
yi a tested irid.w'ere'the results satisfactory T 4"i
c. ore supo ested n were the re8ultj*aatl8faCjo4 ?
W ir;A"'ryfeatures.t a d,
as tested as required ?
.8. ALARMS
;'s. Is the,water motor and gong test satisfactory ?
. . . . . . . . . . . . . . . ...... .
b. Is the electric alarm test satisfactory ? . . . . . . . . . . .
c. Is the supervisory alarm service test satisfactory ? Monitoring Co.
Ph.: ode:-22 --41Z2 eK I I
9. SPRINKLERS - PIPING
a. Are all sprinkler heads In good condition, not obstructed and free from corropi .. . . . . . . . . . . . . .
.Ion or loadin
b. Are all sprinkler heads less than fifty (50) years old ? H ead Manufacturer Date of head
WHITE: VIKING COPY YELLOW:'INVOICE COPY PINK: FIRE DEPARTMENT COPY GOLD: BUILDING COPY
MATIC SPRINKLER COMPANY 3434 RtW Aw So., Sooft. WA 98134, 206. 622. 4656
WA: V1I-KJ-NA-%W73NT LEVEL X 602 CaWanb W, LongvkW WA 3W. 425. MW
Fire Protectio n* Contractors since 1930
VIKING AUTO
Fire Sprinkfer Inspection'Report Page:. 2of 2
9.
SPRINKLER / PIPING (Continued)
YES
N.A.
NO
c. Are extra sprinkler heads rea dily available ? . . . . . .
d. Is condition of piping, drainvalves check valves, han re
go 1p
III. �Urlgl ope sprinklers, and strainers sadfactoiy ?
a. Are all sprinklers of proper -temperature rating?- .
Iwfl
portab_ re extin u1shers In good,condition.7-
.9
g. Is hand hose on sprinkler systems satisfactory ?
--- - - - - - - - - - - - - - - - - - ----
... . . . . . .
10.
Date Dry System Piping last chocked for stoppage. . . . .
. . . . . . . . . . . . . . . ... . . . . . . . . . . .
. .
11.
Date Dry System Piping last checked for proper pitch -----------------------------------
A11A
12.
Date Dry Pipe Valve last trip tested. --- - - - -
- - - - - - - - - - - - - - - - - - - - --- - - - - - - -
-
13.
Wet syster. a: Number- Make Model
/5' V
14.
Dry Systems- Number:—T—Make Model Year:
15.
Accelerator: Make / Model / Year:
,,-.16.,-Ppeclal
Systems: -Number.:., pr
A.
Make Model Year:
Condition
17. CONTROL VALVES
a. City Connection Control Valves - - - - - -
b. Tank Control Valves . . . . . . . . .
c. Pump Control Valves - - - - - - - - -
d. Sectional Control Valves - - -- - - - - - -
a. System Control Valves - - -
Number
Type
Open
Yee No
Secured
Yes No
Closed
-Yee No
Sign
yes No
Condition
z
J;<
18. WATER. FLOW TEST
a. Water Pressure Source :;ffCItj, E37ank, 13 Fire Pump, Water Flow Test taken ? If not, reason:
Test Pipe Location Pressure Belo
Size Test Pipe
re
Flow Pressure
Pressure After
19. Explanation of any "No answers
20. Recent changes In building occupa . ncy or fire protection equipment:—b /f Al'�^ 'dil .1e,,,o A
21. Adjustments or corrections made:
.22. Desir,abl 1 vements:
23. Has building owner representative been notif led of any def lciency to the I Ire protection system? 0 Yes 0 No, Person notIf led:
It answer Is "No",explaln-
24. Inspector's Signature: —Witness (property owner/ lessee) and date:
WHITKrIKIN'G COPW�ELLOW: INVOICE COPY PINK: FIRE DEPARTMENT COPY GOLD: BUILDI . NG COPY.
VIKING AuTomATic SPRINKLER COMI
WA.:%,V1K1-NA-S373NT LEVEL/ft,
Fire P tection Contractors since 1930
3434 Flt�t Ave. So., Seaft, WA 98134, 206. 622. 4656
602 Cafffbmia Way, LwVWw, WA 915W, 360. 425. 7620
COMPANY- L. I hi I o JOB NO.: DATE:
STREET:. 2 we 14 i1w P90PERTY NAME LOCATION:
CITY STATE ew /Wl� �;_0162/1' k�PECTOR
-Valve
description
a. Size
q
b. Make
c. Model
d*.'Year of Mfg.
2.
Control Sprinklers in
3.
Pressure (Lb) before tests
,-a-, Afri
b. Water
4.
Control Valve
a. Wide open
b. No (No.of turns to ope
5.
Operated at:
a. Air pressure (Lb)
b. TimejMin.,Sec.)
6 -,Operation
lri,dicited:
pa. 'Satisfact dry
.,.
b -Partially satisfactory
c . Failed,
-1.
Reason for"
a. failure
b. partially satisfactory
8. Valve reset dry? (yes/no)
9. Condition:
,,o,.Lnterior of body
b. Waterjor test pipe
_g,
c, 1.0 a
M
*!�ri p
LP., S'�ats
" e 'Rubbe'r facing.,
10.Ala,rms operated? e 7/no,
y s
11. Inspector's Testjtip, time (Se
vices.:
12.Quick Opening 0'
a. Make
b.'.Mod6['
LO �2
Signature / TitleyPerson p#rtorming test Witness (owner / lessee of property ) and date signed.
VMng Automatic Sprinkler Co. 3434 1 ST AVE S,SEATTLE,WA 98134
-
Phone (206) 622-4656 Fax (206) 622-9319
IIIII QVIT11 M 11IRW V 101 IN
0:9.191 Mij"-, 0
oo
t "a
Today's Date:
Inspected Date:
Due Date: 9 - x<
Service Test E] Repairs
0
System Location
I-ellf-I P1,1h
Certification Given REDE] YELLOW
WHITE
Occupant Information
Responsible Person
Bldg ame: &rkwev\
GV1jdh,!7
Name: 1A 0 k--%,
Address:
2- '71
&J4.
Address: /2vod Xk,,C //16- 9k-,
P h o n e 7-1/2 — X", 13 e,116 W-A, WA
19967
Email:
�Y, �d
DY
Rkl, 171�
Contractor Information
Inspector/Tester Information
Com any Name: I
Name: 19
Phone: 7
/_g _72.
Address: 7/,7y /5V 4ilZr
Email:
we z
Phone#: Z�r&-&22-
CERTIFICATIONS
State Contractor License #:
State Certification:
License #:
National/NICET:
Other Cert: TYPE:
r., wllr�, Vwl
NOWN1
Central Station Monitoring?
ZY EIN
Phone #: :K(,, 4
V
E3Y-- XR/2
Monitoring Company: -)W#4jV0/j,,j
System Model:
System Make.
DiEFICIENCYICORRECTIOAI'De,,rAiLs,l,
Any Deficiencies Found? ON EAny Deficiencies Remaining? 1:1 Y El N
Deficiencv Found Comments I Corrected? I Correction Date : I Corrected Bv-
C 3
...... ....
N 'T
0
3
Add Review Notes?
0 Y
N
Add Special Instructions?
13 Y
N
Refer to the local and state standards for a complete description of the inspection, testing, and maintenance requirements.
The inspection results provided in this report are based only on the system's current ability to operate and shall not be
construed as an evaluation of the system's performance capabilities to adequately protect the property. Information in this
report may or may not include possible performance concerns and should not be considered all inclusive. It is solely the
property owner's responsibility to determine if a separate investigation should be done to ensure the system will perform
as designed and that the property is adequately protected. It is also the property ownees responsibility to maintain the
system, property and any possible environmental conditions that may affect the system's operability and performance.
SYSTEM
Hydraulic nameplate install6dan.06sible on riser?
0 Yes,-9 No
HYDRAULIC NAMEPLATE INFORMATION
Recorded design densi�?, (gp.rh: per-sq.ft.)
Indicate pipe schedule:
Main Drain flow test condu6ted?''
Drain test pipe size?
Pressure:
Residual Pressure:
Flow switches, supervisory. sw itche s, and alarm bell tested?
IElectric Bell - operates properly?
Water Motor Gong - operates'propqrly?
Central Station monitoring company received signal?
System inspected and lubricated?,
Pipe and valves internally inspected for obstruction? (5 year) 2all
System gauges r6placed'or calibir'ate-d? (5 year) 24911
Was antifreeze solution checked and does system operate properly?
IVALVES
Pressure regulating valves tested?
Valves are sealed, locked, or supervised properly?
Control valves have propersignage?
7J gpm per sq.ft.
0 Light 0 Ordinary 0 Extra
N/A
Yes 0 No
11 inches
psi
psi
Yes 0 No
0
0
0
Yes 0
Yes 0
Yes 0
Yes:O
Yes
Yes 0
Yes 0
No 0 N/A
No 0 N/A
No 0 N/A
No
No 0 N/A
No 0 N/A
No ;W N/A
0 Yes 0 No 0 N/A
;a Yes 0 No
JW Yes 0 No
SPRINKLERS
Number of known sprinklers:
Proper number of spare sprinklers available?
�8`
Yes 0
No
Sprinkler wrench available for each type of sprinkler?
0
Yes 0
No
Sprinklers free of corrosion, paint, and/or physical damage?
0
Yes 0
No
Minimum clearance above top of storage to sprinkler deflector? (11 8"typically)
$R
Yes 0
No
Sprinklers (standard response) are less than 50 years old?
('R
Yes 0
No
0
N/A
Sprinklers (fast response) are less than 20 years old?
0
Yes 0
No
.0
N/A
Sprinklers (dry type) are less than 10 years old?
0
Yes 0
No
0
N/A
Sprinklers (extra high temperature) are less than 5 years old?
0
Yes 0
No
;9
N/A
Sprinkler sample has been successfully tested within last 10 years?
0
Yes 0
No
J&C
N/A
FIRE DEPARTMENT CONNECTION
0
Yes 0
No
FDC visible and accessible? 771� �W -,ell
J8
Yes 0
No
0
N/A
FDC couplings or swivels are undamaged and rotate smoothly?
or
Yes 0
No
0
N/A
FDC plugs or caps are undamaged and in place?
'I.Sr
Yes 0
No
0
N/A
FDC gaskets are in place and in good condition?
�2C
Yes 0
No
0
N/A
FDC Identification signs are in place and readable?
Yes 0
No
0
N/A
FDC check valve is not leaking and in good condition?
0
Yes 0
No
0
N/A
FDC automatic drain valve is in place and operates properly?
0
Yes 0
No
0
N/A
FDC clapper is in place and operating properly?
a
Yes 0
No
0
N/A
-Internal FDC inspection for obstructions conducted? (5 years)
18r
Yes 0
No
0
N/A
INSPECTION COMPLETION
Full walk through performed?
.9
Yes 0
No
Owner has been advised to protect water filled sprinkler piping from freezing?
0
Yes 0
No 0 N/A
System left in service?
0
Yes 0
No
Inspection tag posted at main valve?
70
Yes 0
No
Informed owner of inspection and testing results -and all system deficiencies?
1�2F
Yes 0
No.
By checking here you are certifying, under penalty of perjury, that you are a valid agent of your company representing
that the company maintains all the necessary licenses and/or certifications to perform this service for this system in this
jurisdiction AND THAT the company has properly inspected this system consistent with state and local standards AND
THAT the system has been properly tagged or labeled and the property owner or responsible person has been notified
of the inspection results, the system status, and any corrective actions.
Deficiencies must be corrected within 30 days from time of acceptance of the initial report and updated to show deficiencies
corrected in Tegris.
Viking Automatic Sprinkler Co. 3434 1 ST AVE S,SEATTLE,WA 98134
Phone (206) 622-4656 Fax (206) 622-9319
-r,
7 7.&� 7,0-,�Z
Id <,r-
Today's Date:
Inspected Date:
Due Date: 79-
E] Service Test E] Repairs
System Location Zowc,,
IwAyL
(zv,l &1h -�7
J6,00-
Certification Given RED E]
YELLOW WHITE
Occupant Information
Responsible Person
Bldg Name: Wp11,e,.,j 6fAj'
Name: 07-Lhr-
&-%
Address:
7, A-
Z/ 72? kle
Address: ZtV
Phone: ZLZ Z/0- ��,dj
41
Email:
Contractor Information
Inspector/Tester Information
Company Name: )A-)
Name: 7//-,,l
k
P h o n e 27- - 04ZL
PhoneE4 Ze%;�-' /. 277- W-<Z/
Address: $50' A057 -QX*4-
Email:
3�xi-w TEO M.
�",
CERTIFICATIONS
State Contractor License #:
State Certification:
License
National/NICET:
Other Cert:
TYPE:
gi�, 401
0%
OEM.- R�
19 I 1�
2, Z%�
Central Station Monitoring?
[BY EIN
Phone
Monitoring Company: We-im
110- / b)
System Model:
System Make:
CIENCY1 CORRECTION
Any Deficiencies Found? Ely �31N Any Deficiencies Remaining? 11 Y 13 N
V -Z-
Add Review Notes?
Y N
Add Special Instructions? :0 Y
N
Refer to the local and state standards for a complete description of the inspection, testing, and maintenance requirements.
The inspection results provided in this report are based only on the system's current ability to operate and shall not be
construed as an evaluation of the system's performance capabilities to adequately protect the property. Information in this
report may or may not include possible performance concerns and should not be considered all inclusive. It is solely the
property owner's responsibility to determine if a separate investigation should be done to ensure the system will perform
as designed and that the property is adequately protected. It Is also the property owner's responsibility to maintain the
system, property and any possible environmental conditions that may affect the system's operability and performance.
SYSTEM
Hydraulic nameplate installed and visible on riser?. .
0 Yes3K No
HYDRAULIC NAMEPLATE INFORMATION
Recorded design density? (gpm per sq.ft.)
Indicate pipe schedule:
Main Drain flow test conducted?
Main Drain test pipe size?
Static Pressure:
Residual Pressure:
Trip Test Conducted?
Date of last full Trip Test?
System tripped in:
Flow switches, supervisory alarms, and air maintenance devices tested?
Electric Bell - operates properly?
Water Motor Gong - operates properly?
Central Station monitoring company received signal?,:.,
System inspected and lubricated:
Pip.0 and valves internally inspected -for obstruction?,!
System gauges replaced or calibrated? (5 year) 71011
1. P-4-- ...... .-.-1gpm,pe�rsq.ft.
0 Light 0 Ordinary 0 Extra
,,18C N/A
,81 Yes 0 No
inches
psi
p S i
Partial 0 Full 0. N/A
77-�/qMM-DlDwYYYY)
(9
Yes 0
No
.9
Yes 0
No
0 N/A
0
Yes 0
No
N/A
Yes 0
No
0 N/A
Yes 0
No
0
Yes 0
No
0 l/A
(21'
Yes 0
No
0 N/A
VALVES
Pressure regulating valves tested?
0
Yes 0
No
fi�%
N/A
Valves are sealed, locked, or supervised properly?
1,�4
Yes 0
No
Control valves have proper signage?
0
Yes 0
No
Interior of system valve inspected and cleaned thoroughly?
0
Yes 0
No
0
N/A
SPRINKLERS
Number
of known sprinklers:
Proper number of spare sprinklers available?
Yes 0
No
Sprinkler wrench available for each type of sprinkler?
Yes 0
No
Sprinklers free of corrosion, paint, and/or physical damage?
0
Yes 0
No
Minimum clearance above top of storage to sprinkler deflector? (18"typically)
2C
Yes 0
No
Sprinklers (standard response) are less than 50 years old?
.8
Yes 0
No
0
N/A
Sprinklers (fast response) are less than 20 years old?
0
Yes 0
No
0
N/A
Sprinklers (dry type) are less than 10 years old?
0
Yes 0
No
;9
N/A
Sprinklers (extra high temperature) are less than 5 years old?
0
Yes 0
No
8
N/A
Sprinkler sample has been successfully tested within last 10 years?
0
Yes 0
No
0
N/A
FIRE DEPARTMENT CONNECTION
0
Yes 0
No
FDC visible and accessible? 'mx/
fi3l
Yes 0
No
0
N/A
FDC couplings or swivels are undamaged and rotate smoothly?
0
Yes 0
No
0
N/A
FDC plugs or caps are undamaged and in place?
�9
Yes 0
No
0
N/A
FDC gaskets are in place and in good condition?
.8
Yes 0
No
0
N/A
FDC Identification signs are in place and readable?
Yes 0
No
0
N/A
FDC check valve is not leaking and in good condition?
8
Yes 0
No
0
N/A
FDC automatic drain valve is in place and operates properly?
;�)
Yes 0
No
0
N/A
FDC clapper is in place and operating properly?
0
Yes 0
No
0
N/A
Internal FDC inspection for obstructions conducted? (5 years) 2al
0
Yes 0
No
0
N/A
INSPECTION COMPLETION
Full walk through performed?
8
Yes 0
No
Owner has been advised to protect water filled sprinkler piping from freezing?
6�
r—
Yes 0
No
0
N/A
System left in service?
2F
Yes 0
No
Inspection tag posted at main valve?
Z
Yes 0
No
Informed owner of inspection and testing results and all system deficiencies?
1(k Yes 0
No
W-7 77
ZiNsp
ECTC, C.'',
"V"
By checking here you are certifying, under penalty of perjury, that you are a valid agent of your company representing
that the company maintains all the necessary licenses and/or certifications to perform this service for this system in this
jurisdiction AND THAT the company has properly inspected this system consistent with state and local standards AND
THAT the system has been properly tagged or labeled and the property owner or responsible person has been notified
of the inspection results, the system status, and any corrective actions.
....... .. . , , , - , �4:' "- :� , � !I , ; ' �": �; - , '. , , - , ' ,
I Y 'TI-E, At 4'r
f ORO
Deficiencies must be corrected within 30 days from time of acceptance of the initial report and updated to show deficiencies
-orrected in Tegris.
Fire Pro le C"
4C
VIKING AUTOMA-nC SPRINKLER COMPANY FiLt Aye, 50"
W . I L ja V
A V1-K -NA-S373NT EVEL III n by,
COMPANY: JOB NO.: DATE:-31 -hr- -rov".so,
STREET: 12,7 7 W PROPERTY NAME / LOCATION
CITY / STATE:
INSPECTOR: -
Valve description
a. Size
b. Make
C. Model
d. Year of Mfg.
2. ControP Sprinklers in
3. Pressure (Lb) before tests:
a. Air
b. Water
4. Control Valve
a. Wide open
b. No (No.of turns to open)
5. Operated at:
a. Air pressure (Lb)
b. Time (Min.,Sec.)
6. Operation Indicated:
a. Satisfactory
b. Partially satisfactory
c. Failed
7. Reason for:
a. failure
b. partially satisfactory
8. Valve reset dry? (yes/no)
9. Condition:
a. Interior of body
b. Water for test pipe
c. Moving parts
d. Seats
e. Rubber facing
10.Alarms operated? (yes/no)
11. Inspector's Test trip time (Sec.)
12.Quick Opening Devices:
a. Make
b. Model
c. Year
13.Operation Indictated:
a. Satisfactory
b. Failed.to shut off
14.1-ist of repairs made:
DRY PIPE VALVES
iiiiiiiiiiii."T
I MR5, I P9 WIT 7 ON WJYZA 0 M N
............
QUICK OPENING DEVICES
Signature / 311le of perBffn performing test
Witness (owner / lessee of property ) and date signed.
Omit
-Serving Nieil Edinonds
,NOHOMISH CO.
FIREI
Mo - iintlake Terraceand
DISr"R
the Town of Wbodii�qy
T
www.FireDistrictl.org
LOCATION:
21727 76th Avenue
BUSINESS NAME:
Warreny�edical Center
MAILING
--�l 727 76th Ave W
ADDRESS:
Edmonds
BUSINESS OWNER:
EMERGENCY 1 -1:
AGM/ A. Mathew
KEY ACCESS-2:
FIRE PREVENTION
REPORT
0 EDMONDS
0 BRIER
OWOODWAY
[I MOUNTLAKE TERRACE
0 UNINCORPORATED
FREQUENCY STATION & SHIFT�
365 16 D
SCHEDULED
DATE DUE 1` 1110-1112
UFIR 11, 509 1157
PREFIRE
CURRENT
CITY YES NO
BUSINESS
LICENSE 1:1 . 1:1
INITIAL INSPECTION DATE
PERSON CONTACTED:
NAME OF INSPECTOR:
AS 9/11 FA 4107 V D FE -"1112-
14 ANNUAL
FIRE L_ Il-
�YSTEMS: V/0
12425. Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200
Fax (425) 551-1272
W BLDG
PHONE: 4256404049
98020
HOME PHONE:
HOMEPHONE: 4255763700
HOME PHONE:
HAZARDS FOUND AND LOCATIONS /COMMUNICATIONS
2
14, F-
A)
2
3
3
1.4
4
5
5
1'6
6
7
7
.I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
lst RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTED TO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
I
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
1 5
VIOLATIONS
1 5
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
6
4
18
4
18
DATE:
DISPOSITION:
7
11 LETTER NEEDED E] YES El NO
LETTER NEEDED [-] YES NO
8
FIRE DEPARTMENT COPY
Fire Protection Contractors sinve 1930
OJIVOr vikING AUTOMATIC SPRINKLER COMPANY 3434 First Ave. So., Saittle, WA 981j4, 206.622.'4656
WA.: VI-KI-NA-S373NT LEVEL: N' 602 California Way, Longview, WA 98632,360,425.7620
Fire'Sprinkler Inspebition Report -Page', lof 2.
e J B DATE �2
RE PORTTO' LAw r A I i1j, 0 NO.
STREET: 2 12 22 '74 AlE BLDG./ LOCATION:
CITY/STATE. &JA 9RO*Zte, INSPECTOR: -7
-NO
1.GENERAL YES N.A.
a. Is the building occupied ? . . . . .. . . . . . . . .. . . . .
on ?_
b..Is occupancy the same as previous Inspect.1
C. Are all systems in service ? - - - - - - - . . . . . . --- - - - - - --- - - -
d. Are all fire protection systems the same as last Inspection ? . . . . . . . . . . ... . . .
0. Is the building completely sorinklered ?. . . . . . . .
f. Are all new addItIoris and building changes properly protected ? . ..... . . . . . . . . . ... . . . . . . . .
g. Is all stock or storage properly below sprinkler piping ? . . . . - - - - - - - - - -
7
h. Was property free of fire's since last Inspection ? (Explain any f Ire on Page 2) . . . . . . ... . . . ... . . . . . ..
1. In areas protected by wet syste . nis, is building property heated, Le.: blind attics, perimeter areas, and are all exterior openings protected against the 6old ?
2-CONTROL VALVES (See Section 17),
a. Are all sprinkler system main control valves open ? .. . . . . . ... . . . . . . . ... .
b. Are all other c ontrol valves In proper position ? - — - -
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
c. Are all control valves In good condition and sealed or supervised ? . . . . . . . . .
3. WATER SUPPLIES (See Section i8)
a. Was a water flow test preformed and were the results satisfactory ?
4. TANKS, PUMPS,.& FIRE DEPARTMENT CONNECTIONS
a. Are fire pump , a, gravity tanks, resevoirs and pressure tanks In good condition, and properly maintained
b. Are Fire Department Connections In satisfactory condition, couplings free, caps In place and check valves tight ? . . . . . . . . .
5..WET SYSTEM (See Section 13)
a. Are cold weather valves open or closed as necessa ry ? . . . . .... . . . . . ... . . . ... . . . . . . . . . . . . .
b. Have antifreeze systems been tested and loft In satisfactory condition ? Temp. ? - - - - - - - - -
c. Are alarm valves,water flow Indicators and retard chambe rs. In satisfactory condition. ? . . . . . . . . . . . . ... . . ... ..
6. DRY SYSTEMS (See Section 14)
a. Are.dry valve(s) In service and In good condition ? - - - - - --- - - - - - - - - - - - - --- - - --
7 - - - - --- -
IX
b. Are pressurea.nd priming water levels normal ? . . . . - - - - - - - - - - - - - - - - --- X
. .r
c. Is air compressor In good condition ? - - - - - - - -
d. Wore low points drained during fall and winter Inspections ?
- - - - - - - - - - - - - - . . . . ... . . . . . . . .
a. Are Quick- opening devices in service ? . . . . . . . . . . . . . . . . . . - - - - - --- - - - -
J�d
f. Has piping been checked for stoppage within the past ton (10) years ? . . . . . . . . . . . . . . . . . . . . . . . . . .
g. Has piping been checked for proper pitch within the, past five (5) years ? . . . . . . . . . . - - - - - - - - - - - - - - -
X
h. Have dry valves been trip tested satisfactorily as required ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Are dry valves adequately protected.from freezing ? - - - - - - - - - - - - - - --- -- --- - - - - L Ix
X
J. Are valve house and heater conditions satisfactory ? .. . . . .... . . . . . . . . . . . . . . . . . . . . . . . .
7. SPECIAL SYSTEMS (See Section 16)
a. Were valves tested as required ? . . . . . . . . . . . ...... . ... . . . . . . . . . . . . . . . . . . . . .
b Were all heat -responsive systems tested and were the results satisfactory ? . . . . ... . . . . . . . . . . . . . . . . . . _T
c. Were supervisory features tested and were the results satisfactory, ? - -- - - - - - - -- - - -- - - - - - - - - - - - - - -
8. ALARMS
X
a. Is the water motor and gong test satisfactory ?.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
b. Is the electric alarm test satisfactory ? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0 C'
c. Is the supervisory alarm service test satisfactory ? Monitoring C 2 Al Ph.: 5W ode: vp
9. SPRINKLERS - PIPING
a. Are all sprinkler heads In good condition, not obstructed and free from corrosion or loading ? - - - - - - - - - - - - - -
b. Are all sprinkler heads less than fifty (50) years old? Head Manufacturer: Qx 5x I) 0h Ito I . Date of. head : h ®R
WHITE: VIKING COPY YELLOW: INVOICE CO I PY PINK: FIRE DEPARTMENT CA GOLD: BUILDING COPY
r
V .,Fire'Protoction Contraciots since 1930
VkJkG AUTOMAMC SPRINKLEWCOMPANY 3434 F&W Am Sa, Seaft, WA
98134, 206. 622.4656
'
WA: VN(1-M4-S3nAfr LEVEL W. 602 ChWWO WW: LongvkW WA 360.425.76W
Fike: Sprinkler In ectioh ReoOrt
$p
Page: 2of 2,
9. SPRINKLER/ PIPING (Continued),
YES
-N.A.
NO
c� Are extra sprinkler heads readily eivailable.? . . . . . . . . ... . . . .
7 Al-
dAs condition of piping, drain valves, check valves,'hangers, pressure gauges, open sprinklers, and strainers "dim" ?
A g?
a. re all sprinklersof prdoer'temperature ratin '7.
Are poritable,fire extinguls . .
66m in good condl!l�n'? - - - - - - ----
. . .
.
7
Is hand hose on sprinkler systems satisfactory'?. . . . . . . . . . . ... . . . . .. .. .
7
'10. Date Dry System Piping last �hecked for stoppage.
Date D . .
.11 ry' System Piping last chocked for proper pitch..
. . . .
12. Date Dry Pipe Valve last trip tested.
I Year' A4, e
13. Wet systems: Number Make, I Model
-14. Dry Systems: Number: Make Model Yeam'
15. Acepiprator: Make/ Model iVear:
16. Special Systems: 'Number: Type:
Make Model. Year: -.7
17. CONTROL VALVES
a. City Connection Control Valves -
b.-Tank Control Valves..
C.-Oum
pControl Valves
d. Sectional Control Valves -
a:, System Control Valves - - - - — - -
Number
Type
Open
Yes. No
Secured
Yes No*
C'm N
Yes .�No
-Sign
Yes No'
Condition
16
�57
OW TEST
1& 'WATER FL
if,
a. Water Pressure Source: P.,Clty. 07ank, 0 01rePump, Water Flow, Test taken'? not, reason:
Test Pipe Location
Size Test pipe
Pressure Before
Flo* Pressure
Pressure After
A7-
19. Explanation of any "No" answers:
20. Recent changes In building qccupancy-or fire protection equipment:
21. Adjustments or corrections made:
22., Desirable Improvements:
23. Has building owner / representative been notified of any deficiency to the fire protection system? 0 Yes 0 No, Person notified:
If answer Is "No",explain:
24. Inspector's Signature: Witness (property owner / lessee) and date:
COPY YELLOW: INVOICE COPY PINK: FIRE DEPARTMENT COPY GOLD: BUILDING COPY
-Fire Protection Contractors since 1930
W_ VIKING AUTOMATIC SPRINKLER COMPANY 3434 First Ave. So., Seattle, WA 98134,'206.62,�.4656
WA.: V1.K1-NA_S373NT LEVEL N
602 California Way, Longview,.WA 98632,360,425.7620
Fire Sprinkler Inspection Report Page: 1 of 2
e-,
11 A PfA,; A JOB NO.
,REPORTTO:. DATE.
;STREET: 14,1,e5 V� BLDG.j LOCATION
,'-CITY/ STATE:` Is 524; 6 ..INSPECTOR." Z
I.GENERAL
a. Is the building occupied ? . . . . . . . . . . . . . . . . . . . . . . . ... . . . ... . . . . . . ... . .
b. Is occupancy the same as previous Inspection ? . . . . . . . . . ... . . . . . . . . . . . . ... . . . . . . . .
c. Are all systems In service ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d. Are all fire protection systems the same as last Inspection ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9. Is the building completely sprinklered ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
f. Are all now additions and building changes properly protected ? . . . . . . . . . . . . . . . . . . . . . . . . . .
a -ifock or sio 6
g Is 11 rag properly elowiprlkleirololrig�?��t
h. Was property free of fires since last Inspection ? (Explain any fire on �ags 2) . . . . . . . . . . . . . . . . . ...
1. In areas protected by wet systs ms, Is building properly heated, I.e.: blind atlIcs, perimeter areas, and are all exterior openings protected against the cold
2. CONTROL VALVES (See Section 17)
a. Are all sprinkler system main control valves open ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Are all other control valves In proper position ? . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . .
c. Are all control valves In good condition and sealed or supervised ? . . . . . . . . . . . . . . . . . . . . . . . . . .
3. WATER SUPPLIES (See Section 18
a. Was a water flow test preformed and were the results satisfactory ? ... . . . . .
7 .. . . .. . . . . . ... .
4. TANKS, PUMPS, & FIRE DEPARTMENT CONNECTIONS
a. Are f Ire pumps, gravity tanks, r eseiroirs and pressure tanks In good condition and properly maintained ?.
b. Are Fire Department Connections In satisfactory condition, couplings free, caps In place and check valves tight Z
.5..WET SYSTEMS (See Section 13)
a. Are cold weather valves open or closed as necessary ? . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Have antifreeze systems been tested and left In satisfactory condition ? Temp. ? . . . . . . . ... . . . ... .. . . .
c. Are alarm valves, water flow Indicators and retard �chembers In satisfactory condition ? . . . . . . . . . . . .. ... . . . . . .
6. DRY SYSTEMS (See Section 14)
a. Are dry valve(s) In service and In good condition ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Agepressure and priming water levels normal ? - - - -
a- - - - - - - - - - ,
c;,,l air'cdmpressor In good. condition,? - - - - - -- -
d. W'4e 10"'IL points dirailned during fall and winter Inspections . . . . . . . - - - - - - -- - - - - - - - - _ -
9. Are Quick- opening devices In service .? . . . . . . . . . . . ... . . . . . .
f. Has piping been chocked for stoppage within the past ten (10) years ? . . . . . . . . . . . . . . . . . . . . . . .
g. Has piping been chocked for proper pitch within the past five (5) years ? . . . ... . . . . .
h. Have dry valves been trip tested satisfactorily as required ? . . . . . . . .
- - - - - --- - - - -
1. Are dry valves adequately protected from freezing ? . . . . . . . . ...
1. Are valve house and heater conditions satisfactory ? - . . . . . .. .. . . . .... . . . . . . . . . . . . . . . .
7. SPECIAL SYSTEMS (See Section 16)
-a. Were valves tested as required.?_ . . . . . . . . . . . ... . . . . .. . . . . . .. .
b. Were all heat -responsive systems tested,ind.were the results satisfactory ?
c. Were, suoervisory.features tested and were the results satisfactory.?,
7. 1 - - - - --
8. ALARMS
a. Is the water, motor and gong test* satisfactory. ?. . . . . . . .... . . . . . . ... . . . .. .
b. Is the electric alarm test satisfactory ? - - - - -
- - - - - - . . . . . . .
c. Is the supervisory alarm service test satisfactory ? M onitoring C 75V4C,de:' W- 119/9
9. SPRINKLERS - PIPING
a. Are all sprinkler heads In good condition, not obstructed and free from corrosion or loading ? . . . . . . . . . . . . . .
.1 1p- 0 /7�; �-j
b. Are all sprinkler heads less than fifty (50) years old? Head Manufacturer: _&549 d_0 I ' Date of head :
WHITE: VIKING COPY YELLOW: INVOICE COPY PINK FIRE DEPARTMENT C04 GOLD: BUILDING COPY
.Fire Protection Contractors since 1930 .
vir(ING AuTdmA-ncSPR1NKLER COMPANY 3434 FbW Aw— So., Seaft WA 98134 F 206. 622. 4656
W LongAi*, WA 98M i 3W. 425. MO
A.: VWJ-NA-S373NT LEVEL N 602 CaNkmis
Fire Sprinkler Inspection Report. Page: 2of 2,
9.
SPRINKLER PIPING (Continued)
YES
N.A.
NO
c. Are extra sprinkler heads readily available ? 7 - - - - - - -
d. Is condition of piping, drain,valves, check valves, hangers.,pressure gauges, open sprinklers, and strainers satifactory
1W
a. Are all sprinkle proper temperature rating?
rs o
- - -
f. Are portable fire extinguishers In good condition ?
g. Is hand hose on sprinkler systems satisfactory ?.
7
- --- - - --- -
- -
-10.
11.
12.
Date Dry System Piping last chocked for stoppage .. . .
Date Dry System Piping last checked for proper pitch . . .
Date Dry Pipe Valve last trip tested .. . . . . . . .
. . . . . .. . .
. . . . . . . .
. . . . . . . .
. . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . - - -
. . . .
. . . .
- - - -
13.
14.
Wet systems: Number Make Model Year
Dry Systems: Number: Make Model Year:
Xo�":2411L
NOS/ 27 IM
15.
Accelerator: Make I Model Year:
�"l Systems: Number: Type:
Make / Model / Year:
CondIti6n-:`—,—,
17. CONTROL VALVES
a. City Connection Control Valves - - - - - -
b. Tank Control Valves - - - - - - - - -
c. Pump Control Valves - - - - - - - - -
d. Sectional Control Valves - . . . . . .. .
9. System Control Valves- - - - - - - -
Number
Type
pen
Y.10 No
Secured
Yes No
Closed
Yes No
Sign
Yea No'
Condition
It WATER FLOW TEST
fly,
a. Water Pressure Source :,PAC 137ank, 0 Fire Pump, Water Flow Test taken ?�E� If 'not, mason:
Test Pipe Location
Size Test Pipe
Pressure Before
Flow Pressure,
Pressure After
AT
19. Explanation of any "No" answers:
20. Recent changes In building occupancy or fire protection equipment:
21. Adjustments or corrections made:
iiIkble.'Improveme,is':�
22. Des n
7-
23. Has building owner representative been notifled'of-any deficiency to the fire protection system? 13 Yes 0 No, Person notified:
If answer Is "No",explain:
24. Inspector's Signature*
Witness (property owner / lessee) and date:
YELLOW: INVOICE COPY PINK: FIRE DEPARTMENT COPY GOLD: BUILDING COPY
I-A7
Fire Protection Co ntractors since 1.936
3434 Fus t A ve. So. , Seaft, WA ga 134, 2o6. 622. 4 1 656
602 CARANnia Way, Longvimv, WA 9WX j 3W. 425. 7620
COMPANY- JOB NO.: —DATE:'
7VII
STREET:. Zvf /�_ /, , PROPERTY NAME/ LOCATION:—
'4
0
CITY S E
A y
APENALVE TEST.
Valve d e 6 crr i p t i o n,
0. Size
b. Make
C. Model
d. Year of Mf
2. Control Sprinklers in
3. Pressure (Lb) before tests:
ir . � 7 - I . � -
b. Water
4. Control Valve
a. Wide open
b. No (No.of turns to open)
S. Operated at:
a.... Air press"ure (Lb)
b. Time (Mi.n.,Sec.)
6., Opereition Indicated:
a. 'Satisfactory
b. Partially:sat,isfaclory'
c. Failed
.7. Reason for:
a. failure
b. partially satisfactory
8. Valve reset dry? (yes/.no)
9. Condition:..'
a. Interior of body
b. Water for test pipe
c
-d-;SebT
e. Rubber fac.ing
1O.Alarms-opqrsit6d? (yds/no),
11. Inspector's7dst trip time,(Sec.)
.12.Quick Opening Devices!
a.,Make
b. Model
C. Year
'd
13.0pe,rati6n In i ot a te
d
ta Is'ac or Y,
a i I e d. to s'Kut,of f
1 L.,W I a 150 11 0 ilia uw:.
Title
,)—of person performing test
Witness (ow,ner / lessee of property ) and date signed.
— — — — — — — — — — —
FIRE PREVENTION
v
Sb-ving Brier, Edin6nds
12425 Meridian Ave S
INSPECTION REPORT
SNOHOMISH CO.
Mountlake Terraceand
TIRE
Everett, WA 98208
0 EDMONDS
0 BRIER
the Town of Woodway
STiWT
Phone (425) 551-1200
OWOODWAY
0 MOUNTLAKE TERRACE
www.FireDistrictl.org
Fax (425) 551-1272
0 UNINCORPORATED
e- FREQUENCY
STATION & SHIFT"
LOCATION: 21727 76th Avenue
W BLDG
365.
16 C
BUSINESS NAME: Warren Medical Center
PHONE: 4256404049
SCHEDULED
DATE DUE 11/01111
MAILING 21727 76thAve W
LIFIR 11, 509 1,1157
ADDRESS: Edmonds
98020
BUSINESS OWNER:
HOME PHONE:
PREFIRE
EMERGENCY-1: AGM/ A. Mathew
HOME PHONE: 4255768700
CURRENT
KEY ACCESS-2:
HOME PHONE:
CITY YES NO
BUSINESS
1:1 1:1
LICENSE
PERSON CONTACTED:
INITIAL INSPECTION DATE
NAME OF INSPECTOR: Ilk
-Z- - I
FIRE AS 9/11 FA 4/07
FE I
SYSTEMS: It ) k%
A IiNZI i'L_
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
U
0 YD 0 -r-
1 Im C':� 41
0-e S 11 01
V-' !n, y-g.)
2
2
3
3
4
4
5
by CO
5
6
6
7
7
1 AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1st RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTED TO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
1 5
VIOLATIONS
1 5
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
6
4
8
4
8
DATE:
DISPOSITION:
7
LETTER NEEDED [] YES C3 NO
LETTER NEEDED YES [I kO
8
FIRE DEPARTMENT COPY
WA.: VI-KI-NA-S373NT LEVEL N 602 California Way, Longview, WA 98632,360,425.7620
Fire Protection Contractors since 1930
VIKING AUTOMATIC SPRINKLER COMPANY 3434 First A". So., Seattle, WA 98134, 206.622.4656
Fire Sprinkler Inspection Report Page:lof2
REPORTTO:
JOB NO. r DATE:
STREET:
AV, 4Z
BLDG. / LOCATION:
CITY/ STATE: -'e�QA404te.4
S
INSPECTOR:
I.GENERAL
a. Is the building occupied ? - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
b. Is occupancy the same as previous Inspection ? - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
c. Are all systems In service ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d. Are all fire protection systems the same as last Inspection ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
a. Is the building completely sprinklered ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I. Are all new additions and building changes properly protected ? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
g. Is all stock or storage properly below sprinkler piping ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
_'___h-.Was p!4?psrtyjr a of fires sInce-I t Insp anyjirqqn page 2)
1. In areas protected by wet syste me, Is building property heated, I.e.: blind attics, perimeter areas, and are all exterior openings protected against the cold ?
2. CONTROL VALVES (See Section 17)
a. Are all sprinkler system main control valves open ? . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .
b. Are all other control valves In proper position ? - - - - - - - - - - - - - - - - - - - - - - - - - - - . . . . . .
c. Are all control valves In good condition and sealed or supervised ? . . . . . . . . . . . . . . . . . . . ... . .
3. WATER SUPPLIES (See Section 18)
a. Was a water flow test preformed and were the results satisfactory ? . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. TANKS, PUMPS, & FIRE DEPARTMENT CONNECTIONS
a. Are I Ire pumps, gravity tanks, resevoirs and pressure tanks In good condition and properly maintained ? . . . . . . . . . . . . . . .
b. Are Fire Department Connections In satisfactory condition, couplings free, caps In place and check valves tight ?. M . ,
rsre-o- '- kw - - - -
5. WET SYSTEM (See Section 13)
a. Are cold weather valves open or closed as necessary ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Have antifreeze systems been tested and left In satisfactory condition ? Temp. ? . . . . . . . . . . . . . . . . . . .
c. Are alarm valves, water flow Indicators and retard chambers In satisfactory condition ? . . . . . . . . . . . . . . . . . . . . .
6. DRY SYSTEMS (See Section 14)
a. Are dry valve(s) In service and In good condition ? . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Are pressure and priming water levels normal ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .
c. Is air compressor In good condition ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d. Were low points drained during fall and winter Inspections ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
a. Are Quick- opening devices In service ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... .
I. Has piping been chocked for stoppage within the past ten (10) years ? . . . . . . . . . . . . . . . . . . . .. 120// .
g. Has piping been chocked for proper pitch within the past five (5) years ? . . . . . . . . . . . . . . . . . . . . . . . . .
h. Have dry valves been trip tested satisfactorily as required ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Are dry valves adequately protected from freezing ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Are valve house and heater conditions satisfactory ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7. SPECIAL SYSTEMS (See Section 16)
a. Were valves tested as required ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Were all heat -responsive systems tested and were the results satisfactory ? . . . . . . . . . . . . . . . . . . . . . . . .
c. Were supervisory feetures,tested and were the results satisfactory ? . . . . . . . . . . . . . . . . . . . . . . . . . . .
&ALARMS
a. Is the water motor and gong test satisfactory ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Is the electric alarm test satisfactory ? - - - - - - - - - - - -
c. Is the supervisory alarm service test satisfactory ? Monitoring C
6-e-l'-1 Ph.:Wr2 M" Code:
9. SPRINKLERS - PIPING
a' Are all sprinkler heads In good condition, not obstructed and free from corrosion or loading ? . . . . . . . . . . . . . ... . . .
b. A re 6"ll: sprinkler heads less than fifty (50) years old? Head Manufacturer: k1)5C'-j V1huo4
Date of head : fi-fif lek!
WHITE: VIKING COPY YELLOW: INVOICE COPY PINK: FIRE DEPARTMENT COPY GOLD: BUILDING COPY
"4
Fire.Protection Contractors since-1936
VIKING AUTOMATIC SPRINKLER COMPANY 3434 FM Ava Sa, SeWift WA 90134, 206. 622. 4656
A
WA.: VW4A-WnNT LEVEL Iff 72 C&WbOft NW, LongAw WA. -360.425.7020
Fire Sprinkler Inspection Report Page: 2of 2
9. SPRINKLER PIPING (Continued) YES N.A. NO
c. Are extra sprinkler heads readily -available T . . . . . . ... . . . . . . .
I valves,herho", Pressure gauges strainers sndfwtory;,?
Is condition of piping, dM n valvis;ch'o'ck opap'sprifildem-, and
a. Am all s1prinkler
of Pro g7
f f :Am portable fire :,tInquIp,*
g. Is hand hose, on . ... . . . . .. . . . . .
10. Date Dry System Piping last chocked for stoppage .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
11. Date Dry System Piping last chocked for proper pitch .. . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . . ..
12. Date Dry Pipe Valve last trip tested .. . . . . . . . . . . . . ..... . ..
13. Wet systems: Number. Make model / Year 71 of 7" _K,P 4', 7
14. Dry Systems: Number: Make Model I Year. 4 A&
15. Accelerator: Make / Model I Year:
16. SpecialSystems: Number: —Type:
Maki Model / Year: Condition:
17. CONTROL VALVES
a. City Connection Control Valves - - - - - -
b. Tank Control Valves . . . . . . . . .
c. Pump Control Valves . . . . . . . . .
d. Sectional Control Valves - - - - - - - - -
a. System Control Valves - ; . . . . . . .
A& WATER FLOW TEST
a. Water Pressure Souice_';.&.CItv. 13 Tan . k. 13 Fire Pum I p', Water Flow Tog taken T k--- It not, reason:
—7—
,jestRipe Location
Slim Test Pipe,..
Pressure Before
Flow'Pmasure
PressureAfter
7 _77�
17,
9r
19. Explanation of any "No" answers:
quipmeitt:
,flocent changes In building occupancy or fire protection 9
nts or corrections made: 7-e 'i
21. Adjustme'
�,4 Y 7��
1K.
24. Inspector's Signatu
11 1 - . r — Witness (property owner / losses) and date:
WHITE: VIKING COPY YELLOW: INVOICE COPY PINK: FIRE DEPARTMENT COPY GOLD: BUILDING COPY
""t 1*2
-7
VIKING AuTomA-nc ' .§PRINKLER COMPANY
kire.,Protectio.n, Contractors...sin-ce .1,?30,
3434 Fust Ave. So., SeettIle, WA 98134, 206. 9". 4656
WA.: VPK1-NW-S373AfT LEVEL 1//
6112 Cafifbmia Way, LwigWw, WA. 366.426.7620
COMPANY: JOB NO.: zf,/��
DATE:
STREET: PROPERTY NAME / LOCATION:
CITY STATE INSPECTOR:
SIP
DRY. PIPE -VALVE TE DRY
ST
No -A
PIPE VALVES
No.2,�. N
Valye'.description,
o.'3
a. S'ize
b. Make
C. Model
d - Year of Mf g. j9k
2. Control Sprinklers in
3. Pressure (Lb) before tests:
a. Air
4. Control Valve
a. Wide open
b. No (No.of turns to open)
5. Operated at:
a. Air pressure (Lb)
b. Time (Min.,Sec.)
6. Operation Indicated:
a. Satisfactory
b..P,;3rtially !satisfactory
-'c' F ai I e d
7. Reason1br:,
a. failure
b. partially satisfactory
8. Valve reset dry? (yes/no)
'9. 'Condition:
a. Interior of body
b. Water for, test pipe
c. Moving parts
d. Se��__ k
10.Alarms operated? (yes/no) f
11. Inspector's Test trip time,(Sec�)--
12.Quick Opening , Devices', QUICK
O'P ENI*,NG "DEVICES,
a. Make
b. Model
c. Year
13. 0 p e r a t i o n- I n'd i c t. a t,e d:
Satisfactory
:-b. Faileadd;lo�'ts,hiUt of I
.14. Li's t "'of"' a d
repai -e::
-rs m
Signature / Title of person performing test Witness (owner / lessee of property ) and dke signed.
CITY OF EDMONDS
121 5TH AVENUE N. - EDMONDS, WASHINGTON 98020 - (425) 771-0215
FIRE DEPARTMENT
LOCATION:
21727 76th Avenue
BUSINESS NAME:
Warren Medical Center
MAILING
21727 76th Ave W
ADDRESS:
Edmonds
BUSINESS OWNER:
EMERGENCY-1:
AGrVV A. Mathew
KEY ACCESS-2:
V
PERSON CONTACTED:
NAME OF INSPECTOR:
—
L
FIRE AS 4/06 FA 4/07
SYSTEMS:
HAZARDSFOUNDANDICIC IONS/COMMUNICATIONS
FIRE PREVENTION
SAFETY SURVEY
W BLDG
PHONE: 4256404049
98020
HOME PHONE:
HOMEPHONE: 4255768700
HOME PHONE:
FREQUENCY
STATION& SHIFT
365
16 6
SCHEDULED
DATE DUE 0'
11/01110
UFIRO 509
1'157
PRERRE
INITIAL INSPECTION DATE A
FE I
ANNUAL
ENTER CODE ONLY ONCE 0,
VIOLATION CODE
>
2
2
e,
"i --r7
3
3
4
5
5
6
6
7
7
8
8
lst RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
I
E DUE:
EXTENSION
GRANTED TO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON '!
CONTACTED:
PERSON
CONTACTED:
PERSON
CONT�CTED:
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
1 5
VIOLATIONS
1 5
PRE-CRATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
2
6
DATE:
CODE
SECTION:
5
3
7
13
7
RETURN RECEIPT
RECEIVED
6
4
A 8
4
8
DATE:
DISPOSITION:
7
8
LETTER NEEDED [] YES E] NO
LETTER NEEDED E]l YES NO
FIRE DEPARTMENT COPY
Westfall, John
From: Smith, Mike
Sent: Monday, September 11, 2006 4:44 PM
To: Fire Dept Group
Subject: New and Old Buildings
The Warren Buildid, g
_217.2-7-76WAve W now has it's FD LkBx installed to the left of the main floor glass elevator vestibule
door.
All the keys are there.
The Center for the Arts 410 4th Ave N now has the glitch worked out in the FA monitoring. We should not be getting
anymore false alarm calls.
The fence came down this AM and the trailer is gone. The FD LkBx is now to the right of the glass doors on the NE corner
of the building.
The new Medical Office Building at 21911 76th Ave W now has an active fire sprinkler and fire alarm with monitoring. The
FD LkBx will go up tomorrow. The systems are in service now.
That is all for now.
-Wesdall, John
From: Smith, Mike
Sent: Thursday, August 31, 2006 3:48 PM
To: Fire Dept Group
Subject: New Goings On
Here is some info that may be useful when the occasion arises:
1) Point Edwards 71 and 61 Pine St: the elevator boxes (red) have been moved to the recall floor lobby and I believe I
have sorted out all the keys for all the occupied buildings.
2) The lock boxes have been installed at the Port of Edmonds with keys to the bolt cutter proof locks and chains.
The boxes are located at: On the right side of the building by the gate to the work yard at mid marina;
On the right side gate post by C dock accessing the dry stack storage and our access to A,B, and C/D docks.
On the right side gate post to the dry stack storage by the entrance to Marina Beach.
Next time you are down there check them out. And the key in each key box is a padlock master and will fit all padlocks at
the Port.
3) The Ballinger Court Apts 227th and 76th Ave W now has an LFP Supra box on the West side courtyard entry gate.
Inside the box are keys for the building -and -a -magnetic gate key card.
4) The Warren Build ing-2 1'721-7-6th AvLe—W-now-has-an" active monitored fire alarm which covers the following:
Auto sprinkler (garagEFCnIYTw—iffih wate� flow, tamper, high low air
Pull stations on all floors
Smoke protecting the panel
Inside/outside audio/visual notification.
The FD LkBx is on order and I will advise when it is installed. There are two occupied suites there while the work is going
on.
That is it for now.
-11/20/2002..WED 15:53 FAX 425 640 4448 FINANCIAL SERVICES
1Z 00 1/004
,00�,\
Ste�ens
FACSIMILE COVER SHEET
/? 117n
DATE:
TIME:
r1A
TO:
FROM:
RECEIVING FAX TELEPHONE:
SENDING FAX TELEPHONE: (425) 640-4448 (Financial Services)
NUMBER OF PAGES (including cover): 4-
Please call Diane Byzewski @ (425) 640-4290 if transmission is unclear or if pages are not received.
Fm-essage-
t:
21601 76th Avenue West
Edmonds, WA 98026
(425) 60-4000
ww w. s levenshealthcare, org
11/20/2002 WED 15:53 FAX 425 640 4448 FINANCIAL SERVICES
Z002/004
SJMIPLEX TEUE RECORDER CO.
FME AIA3tM JNSPECnON REPORT
SM: Stevens Memorial Hospital
ALARM R[MATINGDE3XES
PAGE 17
R.jejrA& ZEST RESULTS
Cut
CtLt Addresd Servke
Tea
Dev
-Tw
aundiga
Vgqr
Ar
a
Zone
Dev# Zow No. Performed
&&J—t
ASD
Stevm NUm. HOW-
S
TclowmRoom
M3
M3
006 'resw
007 Tested
Passed
PUS"
DSD
Stevens WM. �W-
SB
Mcch Rom 7 SF-fl
M3
001 Towd
Passed
PSSA
SWCw b1oln. limp.
SB
SurprY SW�-Bas=fft
M3
003 Tested
Passed
RRHO
Stevens Ule-M. HOW.
SB
Surgery SubBase:ne& C
M3
004 Tested
Passed
RRHO
Steyens h4m, ljosp.
SB
Surgery Sub-Baseracat E
M3
002 Tested
Passed
RRHD
Stevens Mem. HOW-
SB;
Surgery Sub-Basemcnt W
Teged
Passed
pjuiD
War," Bldg
0I
01
io i o/s Kitchen Awa
10 1/ 102 Left Office
Tcswd
Passed
ASD
ASD
WarreaBldg
warmusids
01
101/102 Near FACP
Tested.
Passed
/:-9,
warm Bldg
oi
IDIJ102 ols Office*]
Tested
Tested
Passed
passed
-ID
WamnBldw
01
101/102 Office #1
Tested
Passed
ASD
Warren B149
ol
jol/10:Z Office *2
Tested
Piassed.
ASD
warreaBids
01
1011102 09kc 03
Tested
Passod
ASD
Warren 8149
01
101/102 Office #4
Tested
Passed
ASD
Warren Bldg
ol
101/102 Remption
Tested
pas"
ASD
Warren Bldg
oi
1011102 Right Office
Tested
Passed
AF%D
Warren Bldg
01
1011102 Storctom
Tested.
PAssed,
ASD
Warren Bldg
01
Eaft=ce To 101
'rested
Passed
PSSA
warrea Blds
01
Enbw= To 101
Tested
Passed
PSSA
Warten Bldg
01
EntranceTo 102
Tested
Passed
PSSA
Warren Bldg
01
Suite 104
Tested
Passed
ASD
Wan= Bldg
01
Suite 104 From Area
Tested
Passed
ASD
Warrelk Bldg
01
Sdte 104 Rear Arm
Tosted
Passed
ASD
Warren Bldg
02
101/10213Y Rece0onist
Tested
Passed
PSSA
Warren Bldg
02
211 BUM=
Tested
Passed
PSSA
Wamn Bldg
02
211 Rem 5cit
Tested
Passed
ASO
Warren Bldg
02
213 Confen= ROOM
Tested
Passed
PSSA
Warren Bldg
02
213 Entrance
Tested
Passed
ASD
Warren Bldg
02
213 Left Office Area
Tested
Passed
ASD
Warren Bklg
02
213 e/r, Conferem Room
Tested
Passed
ASD
Warm7; Bldg
02
213 US Copy RODM
lftw
--- - — I,- �
11/20/2002 WED 15:54 FAX 425 640 4448 FINANCIAL SERVICES
0003/004
Snf]?LEX TME RECORDER CO.
FUM ALMM WSPECTION REPORT
SnT: Stevens Memorial HosPitlkl
A G 1QF-VICES
DETAIL TUT RXIEL-71
IftEr -AM
,i)
Warren.8148
02
213 Office #1
'I)
wauen Bldg
02
213 Office #2
,j)
WarrenBldg
02
213 Office #3
,D
WarrenBldg
02
213 Office #4
D
Wm= BW9
02
213 Rigitt Office Am
D
WX=Bldg
02
214 Back Office Am
am
wax�ren Bldg
02
214 Break Room
SA
WN=Bldg
02
214 Break Room
iD
War= Bldg
02
214 Copy ROOM
WRTM Bldg
02
2 W CubiclC Am
Warren BWS
02
214 OTxt 'A
5D
Ww=BldS
02
214 Offige #2
SD
Warren Bldg
02
214 0MCe #3
SD
Warren Bldg
02
214 Off!CC #4
SD
Warren Bw9
02
214 Office #5
513
W=80 BWS
02
214 Office #6
SD
WW=BWS
02
2)4 Rewr* Am
SSA
WaF=5149
02
2 17 By RwWOOKifft
lum Warren Bldg
02
217 Kiwben Area
SD
wamnBldo
02
217 0/s Office #4
,SD
warm Bldg
02
217 Office #1
SD
WarrenBldg
02
217 00ice #2
M
Wu=Bidg
02
2 17 Office #3
LSD
Wanen Bldg
02
217 Office 04
kSD
Warm Bldg
02
2j7 Offloce #5
kSD
Warred B1d&
02
Entw= To 211
NSD
warmnBI4
02
EUU*= To 213
ISSA Waum Bldg
02
Euvam To 214
?SSA warreu Bldg
02 Ej&unce To 217
W,
Cast Cust
zM Rig
PAGE 18
Address/ Service
Test
Zpag K9, ftformed
MMI_t
TMW
passed
Tested
Passed
Tested
passed
Tested
Passed
Tested
Passed
Tested
Passed
Tested
Passed
Tested
Passed
Tested
Passed
Tested
Passed
Tested
Passed
Tested
Paw
Toted
Passed
Toted
Passed,
Tested
passed
Tested
Passed
Tested
Passod
Tesw
Passed
Tested
Passed
Tested
Passed
Tested
passed
Tested
Passed
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Passed
Toted
Passed
Tested
Passed
Tested
passed
Tested
Passed
TeMd
passed
Tefiud
passed
11/20/2002 WED 15:54 FAX 425 640 4448 FINANCIAL SERVICES 004/004
A /SIMEPLEX TM RECORDER CO.
FIRE ALARM INSPECTION REPORT PAGE 19
SM: Stevens Memorial Hospital
Mwlf— 0 31RI�"-Allj
SUMMARY TEST RESULTS
Dev.
Number
Number
Number
T
IM Description
Total Tested
FailSa
Not Tested
AIV Audio/Viml Signal Device
4 4
0
0
kv
RMAIL
WX MESUM
Cust 0*1
AddnsW
Service Tat
LUM ftHdirm FkM
AM
kgdomtd Renh
P.S.T.I. I
All on Floor
Tested Passcd
P.S.T.I. 2
All on Floor
Tested Pa
YV Wmvu Bldg 0 1
All on Floor
Tested Pa&wd
VV Wanen B148 02
All on Floor
Tested Passed
IN,
A
,14
a A /
'7��f 77
IAJ6� I
pipe
A)Ae
7-4
INTER -OFFICE COMMUNICATIONS
D
TO FROM
SUBJECT:
z4j&VX4�_ /nc�,.
=;2.1 7 / 7 _/ & �--h
R E C E I V E D
DEC 9 1-0083
TDIVIONDS FIRE DERT.
EDMONDS FIRE DEPARTMENT
DATE:
TO:
FROM: 6?44Gw
SUBJECT: W,949.i-W "Crb
AID
p� 6W7'
,410 /e-1-47 v e -f- c-v�, ern., 7-u:
February 28, 1983
MEMO TO: Hal Reeves
Building Official
FROM: Gary L. McComas
Fire Marshal
SUBJECT: TENANT IMPROVEMENT, 21717-76TH AVENUE WEST, FOR
DOCTOR MARK '
After review, the fire department has the following requirement:
Provide one 2,A-10,B:C dry chemical fire extinguisher
as indicated.
JDW: b e
MV-41! I - W" I - W
LI- -
5,7 � goo - / ��6
March 4, 1982
MEMO TO: Hal Reeves
Building Official
FRO14: Gary L. McComas
Fire Marshal
SUBJECT: TENNANT IMPROVEMENTS AT 21717-76TH AVENUE WEST - THE
WARREN MEDICAL BUILDTNG
The only fire department requirements are as follows:
1. Provide one portable fire extinguisher as indicated
on print. Minimum size 2,A-10,B;C dry chemical type.
2. All waste receptacles are to be metal or non-combust-
ible plastic.
GLII: b e
arCfiiI(,CU, and plariners
%Ljite los - 1),,itk pla7a hi)il(ling
11061 n e. w(und sliect
1-K�14-VI.W. washinglun 9ND04
L,<,-II(-vue 454 9779 scallIe 625-9779
CONFIRMATION RECORD
13 Telephone
Job. No.
Project
80'-05 Client_ Lineberry
Enterpris-es
El Direct
Y- 76 Date March 27, 1981
Edmonds Medigal Office Biilrlinq
Location Edmonds, Washi
Initiator
Individua
McC1;;ri-Sz' Jo rlson, MJ'.1b,-andt
Company
Time 9:00 a.m.
Responder Gary McComas
Fire Marshall,.City of Edmonds
Company
Gary hc�s talked to Harold Reeves, Building Inspector for the City Qf.
Edmonds, re: sprinkler requirements for this proiect.
. Sprinklers are only required in the parking garage belQw the f
G.W.B. ceilinq. No sprinklering is�u�ired
of the garage and the first floor above.
Smoke and fire barriers are rpq1,irPd-in the space decir-ribed.above
per code. This space shall he divided into areas, not fn i-xr-,-(-rl
3000 sq. ft.
These are the sprinkler requirements for this Project.
I I
r-1% X I ,
Copies To:
Client
Location
Action Req.
For Info. Only
x
Copies To:
Location
Action Req.
For Info Only
—
Contractor
Xffice
x
x
McComas V
Edmonds
—
x
Reeves
Edmonds
x
File
MJM
FORM 5-22 (Rev. 7-71 j
To
M/01M ff/Ir sp, r1111CIL01 III,
C 0 R P 0 R A T 1 0 N 0 F A M E R I C A
Z
Attn:
Jo
-ontroct No
Your Index Vile
Your P.O. No.
0 Preliminary Dwg.
We are sending V�t�nl.,.d 0 Shop Drawings
C] Separately 0 Revised Dwgs.
C] Additional Dwgs.
C3 Approved Dwgs.
C] Literaturp
F4- e �tC.rtificate
No..of Dwg. No. Description
Copies
Remor
[I For Approval
C] Per Request
0 For Construction
0oF`6`r_Yo.r Files
Acceptance Inspection
NOTICE TO OWNERS REPRESENTATIVE: Enclosed plans show actual piping arrangement. Elevations are denoted on the plans, also locations from walls, columns,
etc. Your immediate review is requested. If you plan any new additions, equipment or changes in storage and handling or if conflict exists with other trades,
please contact the writer immediately. Plans hove been submitted to the Approving Insurance Authority, and upon receipt of all approvals, plans will be released
for pre-fabricolion.
IN ORDER TO GIVE YOU THE BEST POSSIBLE SERVICE, NO RESPONSE BY WILL INDICATE YOUR ACCEPTANCE AND UPON
RECEIPT OF INSURANCE APPROVALS MATERIAL WILL BE PRE -FABRICATED.
Copies To
Please copies to this office bearing your stomp
of approval or comments.
Very truly yours,
(S5 g n-o/e)
CONTRACTOR'S MATERIAL & TEST 6911TIFICATE
SPRINKLER SYSTEMS - WATER SPRAY SYSTEM
PART "A" GENERAL
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 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 PREJUDICES
ANY CLAIM AGAINST CONTRACTOR FOR FAULTY MATERIAL, POOR WORKMANSHIP, OR FAILURE TO COMPLY WITH APPROVING
AUTHORITY'S REQUIREMENTS OR LOCAL ORDINANCES.
PROPERTY NAME
Edmonds Medical Center
DAT
t-12-81
PROPERTY ADDRESS
218th St. SW & 76th Ave W Edmonds, WA 981H
ACCEPTED BY APPROVING AUTHORITY(S) NAMES
ADDRESS
PLANS
INST,ALLATION CONFORMS TO ACCEPTED PLANS YES NO
EQU PMENT USED IS APPROVED
YES N o F-1
IF NO. STATE DEVIATIONS
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION OF CONTROL VALVES
ANDCAREA N D MAINTENANCE OF THIS NEW EQUIPMENT? YES NO
IFYES, GIVE NAME .............................. ............ a ...................................................................................................... I
INSTRUC-
IF NO. EXPLAIN ............ ... ...... . . .. . .................. . .. .. . ..................................................................................
HAVE COPIES OF APPROPRIATE INSTRUCTIONS AND CARE AND MAINTENANCE CHARTS AND NFPA 13A YES NO
TIONS
BEEN LEFT ON PREMISES?
IFYES. GIVE NAME .....................................................................................................................................................
IFNO. 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 for 4-inch pipe and smaller, 750 gpm for 6-inch pipe, 1000 gpm for 8-Inch pipe, 1500 gpm
for 10-inch pipe, and 2000 gpm for 12-inch pipe. When supply cannot produce stipulated flow rates, obtain maximum available.
HYDROSTATIC:, Hydrostatic tests shall be made at not less than 200 psi for 2 hours or 50 psi above static pressure In excess of
TEST
150 psi. Differential dry -pipe valve clappers shall be left open during test to prevent damage. All aboveground piping leakage shall be
stopped.
DESCRIP-
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 quarts per hour per 100 joints irrespective of pipe diameter. The
TION
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.
New pipe laid with caulked lead or lead -substitute joints shall, If the workmanship Is satisfactory, have little or no leakage at the
joints. Any joint having leakage or more than a "slight drlp" or "weeping" shall be repaired. Leakage shall not exceed I oz. (liquid
measure) per hour per inch of Pipe diameter per joint. The leakage shall be distributed over all joints. If such leakage occurs almost
entirely at a few joints. the installation shall be considered unsatisfactory and necessary repairs made.
PNEUMATIC: Establish 40 psi air pressure and measure drop which shall not exceed 11/2 psi in 24 hours. Test pressure tanks at
normal water level and air pressure, and measure air pressure drop which shall not exceed 11,12 psi in 24 hours.
PART "B" - UNDERGROUND PIPING
FEEDS BLDGS.
LOCATION
PIPE TYPE AND CLA.SS
TYPE JOINT
UNDER-
LDV
CONFORMS TO STANDARD Y E 5 NO
GROUND
IF NO, EXPLAIN
PIPES
AND
JOINTS
JOINTS NA�#,�GANCHORAGE CLAMPED. STRAPPED OR BACKED IN ACCORDANCE YES NO
WITH — STANDARD
IF NO, EXPLAIN
TESTS
REQUIRED
FLUSHING HYDROSTATIC LEAKAGE
NEW UNDERGROUND PIPING FLUSHED ACCORDING TO AJ Flo! PV2 -STANDARD Y E S
BY(COMPANY)
HOW WAS FLUSHING FLOW OBTAINED'
PUBLIC WATEN TANK OR RESERVOIR FIRE PUMP
THROUGH WHAT TYPE OPENING?
FLUSHING
HYD.BUTT. OPEN PIPE
TESTS
LEAD-INS FLUSHED ACCORDING TO —STANDARD YES
BY(COMPANY)
HOW WAS FLUSHING FLOW OBTAINED'
PUBLIC WATER TANK OR RESERVOIR FIRE PUMP
THROUGH WHAT TYPE OPENING?
FLANGE
Y CONN. TO & SPIGOT OPEN PIPE
ASCOA Form 5-2 (Rev. 5-77)
HYDROSTATIC
ALL NEW UNDERGROUND PIPING HYDROSTAYCA 1*1j E5TEO AT min
0
TEST
*so — PSI FOR —.0ugs
TOTAL AMOUNT OF LEAKAGE MEASURED 0
LEAKAGE
— GALS. HOURS
TEST
ALLOWABLE LEAKAGE L)
GALS. HOURS
NUMBER INSTALLED
7RE AND MAKE
i A
HYDRANTS
ALL OPERATE SATISFACTORILY YES NO
WATER CONTROL VALVES LEFT WIDE OPEN
CONTROL
IF NO. STATE REASON YES NO
VALVES
HOSr THREADS OF FIRE DEPARTMENT CONNECTIONS AND HY R T
WeHANGEABLE
WITH THOSE OF FIRE DEPARTMENT ANSWERING ALAR M NO
REMARKS
DATE LEFT IN SERVICE
NAME OF SPRINKLER CONTRACTOR
FO RORERTY 0 ER D) TI
PARTS A & B
FOR SPRINKLER CONTRACTOR (SIGNED)
ATE
SIGNATURES
TESyfi WITNESSED BY It,/ T I TL't -ATE
1-17 PART "C" — SPRV(XER & WAT�—RSPRAY ABOVEGROUND PIPING (Fill out separate Part "C" for each riser)
SERVES BLDGS.
LOCATION
TESTS
I HYDROSTATIC TEST OF ALL PIPING 3 EQUIPMENT OPERATION TESTS OF ALL EQUIPMD(T
REQUIRED
2 PNEUMATIC TEST OF ALL DRY PIPING 4 DRAIN TEST
SPRINKLERS
MA E
MODEL
SIZE
QUANTITY
.1
TENVIIERATURE RATING
OR
SPRAY
NOZZLES
PIPE AND
ORMS T
MATERIAL AND KIN D STANDARD
FITTINGS
IF NON E, EXPLAIN
ALARM VALVE
ALAXM DEVICE
MAXIMUM 14E TO OPERATE THROUGH TEST PIPE
OR FLOW
TYPE
KE
MODEL
I N
SEC.
I
�s
INDICATOR
OPENA ING TEST RESULTS
TIME
'&WMGEHTOFTRIP
TRIP
WATER
TH R T _ ST PIPE
POINT
REACHED
ALARM
W1 THOU
W1 TH
DRY
SERIAL
WATER
AIR
AIR
TEST
OPERATED
MAKE
MODEL
NO.
0.0. D.\
Q.0 . D.
PRESS-
PRESS.
PRESS.
OUTLET
---
PROPERLY
PI PE
I
VALVES
MIN-7
SEC.
MIN.
C.
PSI
PSI
PSI
M 1
.1 E C.
—r--
I
N
I'F NO, EXPLAIN
OPERATION PNEUMATIC '*VLECTRIC HYDRAULIC
PIPING SUPERVISED YES N I DETECTING MEDIA SUPERVISED YES NO
DELUGE
DOES VALVE OPERATE FROM THE MANU4RIP AND/01\REMOTE CONTROL STATIONS? YES N 0
&
IS THERE AN ACCESSIBLE FACILITY CIRCUIT FO G.
YES NO
/ACH
IF NO, EXPLAIN
PREACTION
Does each circ u it a
Does each circuit orrOte
Maximum time to
VALVES
MAKE
MODE/
supervision loss �'j
valve release.
operate release
YES
NO
YES
NO
---
MIN.
SEC
ALL P:P:NG HYDRMOSTATI 1, LILY TESTED AT— PSI FOR— HOURS
D PNEU AT'C L
RY P NG T IC. LLY TESTED YES NO
\
TESTS
EQUIPMANT OPERATF/OPERLY
YES NO
IF NO, S TATE REASO
Drait,Teist: Reading of g cared near water supply test pipe: Res, pressure with valve in test pipv upen wide:
8yo
Static Pressure psi psi
BLANK TESTING
NUMBER USED
LOCATIONS UMBER REMOVED
GASKETS
WELDED OR
S
IF YES. DO OU CERTIFY AS THE SPRINKLER CONTRACTOR THAT THE WELDER, ARE QUALIFIED FOR
BRAZED PIPING
\R�RAZERS
WELDING R BRAZING.IN ACCORDANCE WITH THE REQUIREMENTS OF ASME BOI AN D PRESSURE VESSEL CODE.
/,
'X*
SECTIO IX' QUALIFICATION STANDARD FOR WELDING AND BRAZING PROC WELDERS. BRAZER*. AND
E_'
Yes El No
W E L 1), G AN. BRAZING OPERATORS - 1968 EDITION. YES No
DATE/iFT IN SERVICE WITH ALL CONTROL VALVES OPEN
REMARKS
NAME OF SPRINKLER CONTRACTOR FOR
PROPERTY OWNER tSIGNED) TIILE
"C"
PART
FOR SPRINKLER CONTRACTOR (SIGNED)
SIGNATURES
TESTS WITNESSED BY TITLE
JOATE
CONTRACTOR'S MATERIAL & TEST RTIFICATE
SPRINKLER SYSTEMS - WATER SPRAY SYSTEM
PART "A" GENERAL
670 - 7468
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 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 15 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 A Te_
Edmonds Medical Center
12-81
PROPERTY ADDRESS
218th St. SW & 76th Ave W Edmonds, WA 181H
ACCEPTED BY APPROVING AUTHORITY(S) NAMES
ADDRESS
PLANS
INSTALLATION CONFORMS TO ACCEPTED PLANS YES N 0 C�]
EQUIPMENT USED IS APPROVED YES NO
IF NO. STATE DEVIATIONS
HAS PERSON I N CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION OF CONTROL VALVES
AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT? YES N 0
IF YES. GIVE NAME ................................... ............. ..............................
INSTRUC-
IF NO. EXPLAIN ........... .. .... . . .... ...... ................... .......... . .... . .. .. . .. .. ......................... . .............................. .
HAVE COPIES OF APPROPRIATE INSTRUCTIONS AND CARE AND MAINTENANCE CHARTS AND NFPA 13A YES NO
TIONS
BEEN LEFT ON PREMISES?
IFYES, GIVE NAME .....................................................................................................................................................
IFNO, EXPLAIN ...........................................................................................................................................................
FLUSHING: Flow the required rate until water is clear as In'dicated 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 for 4-inch pipe and smaller, 750 gpm for 6-Inch pipe, 1000 gpm for 8-inch pipe, 1500 gpm
for 10-inch pipe, and 2000 gpm for 12-inch pipe. When supply cannot produce stipulated flow rates, obtain maximum available.
HYDROSTATIC: Hydrostatic tests shall be made at not less than 200 psi for 2 hours or 50 psi above static pressure In excess of
TEST
150 psi. Differential dry -pipe valve clappers shall be left open during test to prevent damage. All aboveground piping leakage shall be
stopped.
DESCRIP-
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 Quarts per hour per 100 joints Irrespective of pipe diameter. The
TION
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.
New pipe laid with caulked lead or lead -substitute joints shall, if the workmanship Is satisfactory, have little or no leakage at the
joints. Any joint having leakage or more than a "slight drip" or "weeping" shall be repaired. Leakage shall not exceed 1 oz. (liquid
measure) per hour per inch of pipe diameter per joint. The leakage shall be.distributed over all joints. If such leakage occurs almost
entirely at a few joints, the installation shall be considered unsatisfactory and necessary repairs made.
PNEUMATIC: Establish 40 psi air pressure and measure drop which shall not exceed 1Y2 psi 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 in 24 hours.
PART "B" — UNDERGROUND PIPING
FEEDS BLDGS.
LOCATION
PIPE TYPE AND CL S
TYPE JOINT
Ov, 4L_ i,
q 15— Z
UNDER
,
CONFORMS TO— A-d — STANDARD Y E S NO
GROUND
IF NO. EXPLAIN
PIPES
AND
JOINTS Nff.#J.�G,41SICHORAGE CLAMPED. STRAPPED OR BACKED IN ACCORDANCE YES NO
JOINTS
WI TH — STANDARD
IF NO . EXPLAIN
TESTS
REQUIRED
FLUSHING HYDROSTATIC LEAKAGE
NEW UNDERGROUND PIPING FLUSHED ACCORDING TO -STANDARD Y E S 11;.�
BY(COMPANY)
HOW WAS FLUSHING FLOW OBTAINED'
'T N?
PUBLIC WA E TANK OR RESERVOIR FIRE PUMP
THROUGH WHAT TYPE OPENING?
FLUSHING
HYC.BUTT. OPEN PIPE
TESTS
LEAD-INS FLUSHED ACCORDING TO tyPI)OO —STANDARD YES
BY(COMPANY)
HOW WAS FLUSHING FLOW OBTAfNEDI
PUBLIC WATER TANK OR RESERVOIR FIRE PUMP
IV
THROUGH WHAT TYPE OPENINZ?
Y CONN. TO FLANGE & SPIGOT OPEN PIPE
ASCOA Form 5-2 (Rev. 5-77)
HYDROSTATIC
ALL NEW UNDERGROUND PIPING HYDROSTA�YCA ESTED AT Min
TEST
0 PSI FOR HOUR9
TOTAL AMOUNT OF LEAKAGE MEASURED
LEAKAGE
GALS. HOURS
TEST
ALLOWABLE LEAKAGE
GALS. HOURS
NUMBER INSTALLED
1
TYPE AND MAKE
HYDRANTS
4
ALL OPERATE SATISFACTORILY f lk*' —660. YES NO
WATER CONTROL VALVES LEFT WIDE OPEN
CONTROL
IF NO. STATE REASON YES N 0 F7-1
VALVES
HOSE THREADS OF FIRE DEPARTMENT CONNECTIONS AND HYWDRTt;1 BLE
WITH THOSE OF FIRE DEPARTMENT ANSWERING ALA R M? �HANGEA NO
REMARKS
DATE LEFT IN SERVICE
NAME OF SPRINKLER CONTRACTOR FO ROPERTY 0 ER( T�1� E
PARTS A & B
,0 A
F, EWA;
FOR SPRINKLER CONTRACTC;R (SIGNED) ATE
f,4deY!�v
SIGNATURES
e-�4
,0 WITNESSED BY
TE S C," TITILE�,
fej!�21.A2
DATE
- -
PART "C" — SP R6� ER &WATER SPRAY ABOVEGROUND PIPING (Fill out separate Part "C" for each riser)
BLDGS.
LOCATION 6.1EIVES
TESTS
I HYDROSTATIC TEST OF ALL PIPING 3 EQUIPMENT OPERATION TESTS OF ALL EQUIPMEt(i
REQUIRED
2 PNEUMATIC TEST OF ALL DRY PIPING 4 DRAIN TEST
SPRINKLERS
MAKE
MODEL
SIZE .
QUANTITY
TE�� ERATURE RATING
OR
,PRAY
NOZZLES
PIPE AND
MATERIAL AND KIND
'\ONFORMS TO STANDARD
FITTINGS
IF NONE, EXPLAIN \ ZZ
ALARM VALVE
ALNM DEVICE
MAXIMUM POE TO OPERATE THROUGH TEST PIPE
TYPE
KE
MODEL
.101,11 IN.
SEC.
OR FLOW
�s
INDICATOR
-kATI
OPE NG TEST RESULTS
TIME
T 0 TRIP
/AT
TRIP
WATER
HNN&IPME
T R GH TEST PIPE
POINT
REACHED
ALARM
WITHOU
WITH
DRY
SERIAL
W E IR
AIR
AIR
TEST
OPERATED
MAKE
MODEL
NO.
0. 0. DN
I Q. 0. D.
PRESS.
PRESS.
PRESS.
OUTLET
PROF ERLY
PIPE
--
I
VALVES
MI N.7
SE\j
MIN. I S��C.
PSI
PSI
PS11
MIN.
SEC.
I
IF NO. EXPLAIN
OPERATION PNEUMATIC ECTRIC. HYDRAULIC
PIPING SUPERVISED YES N I DETEC ING MEDIA SUPERVISED YES NO
DELUGE
DOES VALVE OPERATE FROM THE MANU4RIR AND/O`NREM�TE CONTROL STATIONS' YES N 0
&
IS THERE AN ACCESS!eLE FACILITY CIRCUIT FORNII�TING7 YES NO
/NACH
IF NO. EXPLAIN
PREACTION
Does each circuit ofaerrmate
Does each circuit orrOte
Maximum time to
VALVES
MAKE
MODE
supervision loss a ?
valve release.
operate release
YES
NO
YES
NO
MIN.
SEC
ALL P:PING HYDROSTATI ALLY TESTED AT— RSI FOR HOURS
DRYIP PING PNEUMATIC LLY TESTED YES = No =
TESTS
EQU PMANT OPERATE OPERLY
YES = NO =
IF NO. TATE REASOE
S 0
Draiii Test: Reading of gejIrocpteql npar water supply test pipe: Resi pressure with valve in test pipe upen wide:
Static Pressure — psi psi
BLANK TESTING
NUMBER USED
LOCATIONS
I
NUMBER REMOVED
GASKETS
WELDED OR
R BR
IF Y1ft.D21"YOU CErTI1Y AS THE SPRINKLER CONTRACTOR THAT THE WELDERS\. AZERS ARE QUALIFIED FOR
BRAZED PIPING
WELD, RA _IN G IN ACCORDANCE WITH THE REQUIREMENTS OF ASNIE BOIL AND PRESSURE VESSEL CODE.
__U
SECTIO/IX. QUALIFICA-TION STANDARD FOR WELDING AND BRAZING PROCEDU ES,WELDERS. BRAZERS,. AND
Yes F-1 No
'0
WEL Cy, G AND BRAZING OPERATORS - 1968 EDITION. YES F NO
DATE EFT IN SERVICE WITH ALL CONTROL VALVES OPEN
REMARKS
ly
NAME OF SPRINKLER CONTRACTOR
OR PROPERTY OWNER tSIGNED) TITLE
"C"
PART
FOR SPRINKLER CONTRACTOR ISIGNED)
SIGNATURES
TESTS WITNESSED By TITLE DATE
CONTRACTOR'S MATERIAL & TEST CERTIFICATE
SPRINKLER SYSTEMS - WATER SPRAY SYSTEM
PART "A" GENERAL
PROCEDU RE
UPON COMPLETION OF WORK, INSPECTION AND TESTS SHALL BE MADE BY THE CONTRACTOR'S REPRESENTATIVE AND WITNESSEC,
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 PREJUDICES
ANY CLAIM AGAINST CONTRACTOR FOR FAULTY MATERIAL, POOR WORKMANSHIP, OR FAILURE TO COMPLY WITH APPROVING
ALITHORITY'S REQUIREMENTS OR LOCAL ORDINANCES.
PROPERTY NAME DATE
A'17
�)_.S 5
PROPERTY A9DRF
ACCEPTED BY APPROVING AUTHORITY(S) NAMES
ADDRESS
PLANS
INSTALLATION CONFORMS TO ACCEPTED PLANS YES NO
EQU I PMENT USED IS APPROVED YES NO
IF NO. STATE DEVIATIONS
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION OF CONTROL VALVES
YES
ANDCAREA N D MAINTENANCE OF THIS NEW EQUIPMENT? NO
IFYES, GIVE NAME .........................................................................................................................................................
INSTRUC-
IF NO. EXPLAIN ........... ... ..... ........ ............ .. ........ .. ........ . . .. ...............................................................................
HAVE COPIES OF APPROPRIATE INSTRUCTIONS AND CARE AND MAINTENANCE CHARTS AND NFPA 13A YES NO
TIONS
BEEN LEFT ON PREMISES?
IFYES, GIVE NAME .....................................................................................................................................................
IFNO, 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 for 4-inch pipe and smaller, 750 gpm for 6-Inch pipe, 1000 gpm for 8-inCh Pipe, 1500 gpm
for 10-inch pipe, and 2000 gpm for 12-inch pipe. When supply cannot produce stipulated flow rates, obtain maximum available.
HYDROSTATIC: Hydrostatic tests shall be made at not less than 200 psi for 2 hours or 50 psi above static pressure In excess of
TEST
150 psi. Differential Cry -pipe valve clappers shall be left open during test to prevent damage. All aboveground piping leakage shall be
stopped.
DESCRIP-
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 quarts per hour per 100 joints irrespective of pipe diameter. The
TION
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.
New pipe laid with caulked lead or lead -substitute joints shall, If the workmanship is satisfactory, have little or no leakage at the
joints. Any joint having leakage or more than a "slight drip" or "weeping" shall be repaired. Leakage shall not exceed I oz. (liquid
measure) per hour per inch of pipe diameter per joint. The leakage shall be distributed over all joints. If such leakage occurs almost
entirely at a few joints, the installation shall be considered unsatisfactory and necessary repairs made.
PNEUMATIC: Establish 40 psi air pressure and measure drop which shall not exceed 11/2 psi in 24 hours. Test pressure tanks at
normal water level and air pressure, and measure air presiure drop which shall not exceed 1112 psi in 24 hours.
PART "B" — UNDERGROUND PIPING
FEEDS BLDGS.
LOCATION
PIPE TYPE AND CLASS
JOINT
UNDER-
CONFORMS TO STANDARD Y ES N 0
GROUND
IF NO. EXPLAIN
PIPES
AND
JOINTS
JOINTS NEEDING ANCHORAGE CLAMPED, STRAPPED OR BACKED IN ACCORDANCE YES NO
WITH STANDARD
IF NO. EXPLAIN
TESTS
FLUSHING HYDROSTATIC LEAKAGE
REQUIRED
NEW UNDERGROUND PIPING FLUSHED ACCORDING TO STANDARD YES
BY(COMPANY)
HOW WAS FLUSHING FLOW OBTAINED?
PUBLIC WATER TANK OR RESERVOIR FIRE PUMP
THROUGH WHAT TYPE OPENING?
FLUSHING
HYD.BUTT. OPEN PIPE
TESTS
LEAD-INS FLUSHED ACCORDING TO STANDARD YES
BY(COMPANY)
HOW WAS FLUSHING FLOW OBTAINED?
PUBLIC WATER TANK OR RESERVOIR FIRE PUMP
THROUGH WHAT TYPE OPENIN�G?
Y CONN. TO FLANGE 5 S�IGOT OPEN PIPE
ASCOA Form 5-2 (Rev. 5-77)
HYDROSTATIC
ALL NEW UNDERGROUND PIPING HYDROSTATICALLY TESTED AT
TEST
PSI FOR HOURS
TOTAL AMOUNT OF LEAKAGE MEASURED
LEAKAGE
GALS. HOURS
TEST
ALLOWABLE LEAKAGE
GALS. HOURS
NUMBER INSTALLED
TYPE AND MAKE
HYDRANTS
ALL OPERATE SATISFACTORILY YES NO
WATER CONTROL VALVES LEFT WIDE OPEN
CONTROL
IF NO, STATE REASON YES NO
VALVES
HOSE THREADS OF FIRE DEPARTMENT CONNECTIONS AND HYDRANTS INTERCHANGEABLE
WITH THOSE OF FIRE DEPARTMENT ANSWERING ALARM? YES NO
REMARKS
DATE LEFT IN SERVICE
NAME OF SPRINKLER CONTRACTOR
FOR PROPERTY OWNER (SIGNED) TITLE
PARTS A & B
FOR SPRINKLER CONTRACTOR (SIGNED) DATE
SIGNATURES
TESTS WITNESSED BY TITLE DATE
PART "C" - SPRINKLER & WATER SPRAY ABOVEGROUND PIPING (Fill out separate Part "C" for each riser)
SERVES BLDGS.
LOCATION
evu "Alewos /25,�rhie,%,4
TESTS
I HYDROSTATIC TEST OF ALL PIPING 3 EQUIPMENT OPERATION TESTS OF ALL EQUIPMENT
REQUIRED
2 PNEUMATIC TEST OF ALL DRY PIPING 4 DRAIN TEST
SPRINKLERS
MAKE
MODEL
SIZE
QUANTITY
TEMPERATURE RATING
OR
SPRAY
NOZZLES
PIPE AND
MATERIAL AND KIND CONFORMS TO 411 Ar -40IA7 STANDARD
FITTINGS
IF NONE, EXPLAIN
ALARM VALVE
ALARM DEVICE
MAXIMUM TIME TO OPERATE THROUGH TEST PIPE
OR FLOW
TYPE
MAKE
MODEL
MI N.
SEC.
INDICATOR
--- 7—
Mo 2
:2 /
40
OPERATING TEST RESULTS
TIME
T I ME TO TRIP
TRIP
WATER
THROUGH TEST PIPE
POINT
REACHED
ALARM
SERIAL
WITHOUT
WiT�ej
DRY
WATER
AIR
AIR
TEST
OPERATED
MAKE
MODEL
NO.
Q. 0. D.
0. of.
PRESS.
R R E S S.
PRESS.
OUTLET
PROP ERLY
PIPE
VALVES
MI N.
SEC.
C.
PSI
PSI
PSI
MIN.
YC.
YES N
NNAFa��
I
IF NO, IiXPLAIN
OPERATION PNEUMATIC ELECTRIC HYDRAULIC
PIPING SUPERVISED YES NO I DETECTING MEDIA SUPERVISED YES NO
DE GE
DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATIONS? YES NO
IS THERE AN ACCESSIBLE FACILITY IN' EACH CIRCUIT FOR TESTING?
YES NO
IF NO, EXPLAIN
P E' TION
Does eack circuit operate
supervision loss alarm?
Does each circuit ortate
valve release,
Maximum time to
operate release
��AALVES
MAKE
MODEL
YES
NO
NO
-
MIN,
SEC.
ALL P:P:NG HYDROSTATICALLY TESTED AT 2 1212 -�s, FOR HOURS
DRY,R P NG PNEUMATICALLY TESTED Y ES [jZ'I NO =
TESTS
EOU PMANT OPERATE PROPERLY
YES ig NO =
IF NO, STATE REASON
Drain Test: Reading of gage Iocaw�,npear water su%Ket pipe; Residual pressure with valve in.r?tt n wide;
Ste ressure Psi %�� Psi
BLANK TESTING
NUMBER
L 11 C A T 1 ON S NUMBER REm(5vffb
GASKETS
WELDED OR
IF YES. DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT THE WELDERS OR PRAZERS ARE QUALIFIED FOR
BRAZED PIPING
WELDING OR BRAZING IN ACCORDANCE WITH THE REQUIREMENTS OF ASME BOILER AND PRESSURE VESSEL CODE.
YesA No ED
SECTION IX, QUALIFICATION STANDARD FOR WELDING AND BRAZING PROCEDURES. WELDERS. eRAZERS' AND
WELDING AND BRAZING OPERATORS - 1968 EDITION. YES NO E3
DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN
REMARKS
)ONI- �- z / '? s-/ I
NAME OF SPRINKLER d'ONTRACTOR FORIPROPERTY
OWNER (SH D) TITLE
)<j
A47o-#4T,4-- .5AA1AJWLfX
PART "C
FOR SP I KLER CONTRACTOR (StGNE
SIGNATUR ES
TESTS VV T E D 5 Y TITLE
DAT:E�
yk 4 -
7, fPv71r -Itel: 06�07"
CONTRACTOR'S MATERIAL & TEST CERTIFICATE
SPRINKLER SYSTEM - WATER SPRAY SYSTEM
PART "A" GENERAL
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 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 PREJUDICES
ANY CLAIM AGAINST CONTRACTOR FOR FAULTY MATERIAL, POOR WORKMANSHIP, OR FAILURE TO COMPLY WITH APPROVING
AUTHORITY'S REQUIREMENTS OR LOCAL ORDINANCES.
PROPERTY NAME
DATE
� A
PROPERTY AQDF
ACCEPTED BY APPROVING AUTHORITY(S) NAMES
ADDRESS
PLANS
INSTALLATION CONFORMS TO ACCEPTED PLANS YES NO
EQUIPMENT USED :S APPROVED YES NO
IF NO. STATE DEV ATION S
HASPERSON I NCHARGEOFFIRE EQUIPMENTBEEN INSTRUCTED AS TO LOCATION OF CONTROL VALVES
AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT? YES NO
IFYES, GIVE NAME ..........................................................................................................................................................
INSTRUC-
IF NO. EXPLAIN ....... ... ......... ........... .......... ..... ...... . .... . . ... . ... ......................................................................
HAVE COPIES OF APPROPRIATE INSTRUCTIONS AND CARE AND MAINTENANCE CHARTSAND NFPA 13A YES NO
TIONS
BEEN LEFT ON PREMISES?
IFYES. GIVE NAME ................................. I ......................................................................................... I .........................
IFNO. 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 for 4-inch pipe and smaller, 750 gpm for 6-inch pipe, 1000 gpm for 8-Inch pipe, 1500 gpm
for 10-inch pipe, and 2000 gpm for 12-inch pipe. When supply cannot produce stipulated flow rates, obtain maximum available.
HYDROSTATIC; Hydrostatic tests shall be made at not less than 200 psi for 2 hours or 50 psi above static pressure In excess of
TEST
150 psi. Differential dry -pipe valve clappers shall be left open during test to prevent damage. All aboveground piping leakage shall be
stopped.
DESCRIP-
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 quarts per hour per 100 joints irrespective of pipe diameter. The
TION
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.
New pipe laid with caulked lead or lead -substitute joints shall, If the workmanship is satisfactory, have little or no leakage at the
joints. Any joint having leakage or more than a "slight drip" or "weeping" shall be repaired. Leakage shall not exceed I oz. (liquid
measure) per hour per inch of pipe diameter per joint. The leakage shall be distributed over all joints. If such leakage occurs almost
entirely at a few joints, the installation shall be considered unsatisfactory and necessary repairs made.
PNEUMATIC: Establish 40 psi air pressure and measure drop which shall not exceed 11/2 psi In 24 hours. Test pressure tanks at
normal water level and air pressure, and measure air pressure drop which shall not exceed 1112 psi in 24 hours.
PART "B" — UNDERGROUND PIPING
FEEDS BLDGS.
LOCATION
PIPE TYPE AND CLASS
TYPE JOINT
I
UNDER-
GROUND
CONFORMS TO STANDARD YES NO
IF NO, EXPLAIN
PIPES
AND
JOINTS
JOINTS NEEDING ANCHORAGE CLAMPED, STRAPPED OR BACKED IN ACCORDANCE YES NO
WITH STANDARD
IF NO. EXPLAIN
TESTS
REQUIRED
FLUSHING HYDROSTATIC LEAKAGE
NEW UNDERGROUND PIPING FLUSHED ACCORDING TO STANDARD YES
BY(COMPANY)
HOW WAS FLUSHING FLOW OBTAINED?
PUBLIC WATER TANK OR RESERVOIR FIRE PUMP
THROUGH WHAT TYPE OPENING?
FLUSHING
HYC.BUTT. OPEN PIPE
TESTS
LEAD-INS FLUSHED ACCORDING TO STANDARD YES
BY(COMPANY)
HOW WAS FLUSHING FLOW OBTAINED?
PUBLIC WATER TANK OR RESERVOIR FIRE PUMP
THROUGH WHAT TYPE OPENIN6?
Y CONN. TO FLANGE & SPIGOT OPEN PIPE
ASCOA Form 5-2 (Rev. 5-77)
HYDROSTATIC
ALL NEW UNDERGROUND PIPING HYDROSTATICALLY TESTED AT
TEST
PSI FOR HOURS
TOTAL AMOUNT OF LEAKAGE MEASURED
LEAKAGE
G A LS. HOURS
TEST
ALLOWABLE LEAKAGE
GALS. HOURS
NUMBER INSTALLED
M AKE
HYDRANTS
ALL OPERATE SATISFACTORILY
YES NO
WATER CONTROL VALVES LEFT WIDE OPEN
CONTROL
IF NO, STATE REASON YES NO
VALVES
HOSE THREADS OF FIRE DEPARTMENT CONNECTIONS AND HYDRANTS INTERCHANGEABLE
WITH THOSE OF FIRE DEPARTMENT ANSWERING ALARM? YES NO
REMARKS
DATE LEFT IN SERVICE
NAME OF SPRINKLER CONTRACTOR
FOR PROPERTY OWNER (SIGNED) TITLE
PARTS A & B
FOR SPRINKLER CONTRACTOR (SIGNED)
ATE
SIGNATURES
TESTS WITNESSED BY TITLE
DATE
PART "C" —SPRINKLER& WATER SPRAY ABOVEGROUND PIPING (Fill out separate Part "C" for each riser)
SERVES BLDGS.
LOCATION
TESTS
I HYDROSTATIC TEST OF ALL PIPING 3 EQUIPMENT OPERATION TESTS OF ALL EQUIPMENT
REQUIRED
2 PNEUMATIC TEST OF ALL DRY PIPING 4 DRAIN TEST
SPRINKLERS
MAKE
MODEL
SIZE
QUANTITY
TEMPERATURE RATING
OR
:A��Aozx'c-
4�p/� /6w;r
SPRAY
NOZZLES
PIPE AND
MATER!AL AND KIND CONFORMS TO — IJ A? STANDARD
FITTINGS
IF NONE, EXPLAIN r- -
ALARM VALVE
ALARM DEVICE
MAXIMUM TIME TO OPERATE THROUGH TEST PIPE
OR FLOW
T Y P E
WAKE
MODEL
MIN.
SEC.
INDICATOR
q j
4"rl� /" T1 e-
I /
OPERATING TEST RESULTS
T IM E
T I ME TO TRIP
TRIP
W ATER
T H R OUGH TEST PIPE
POINT
REACHED
ALARM
WITHOUT
WIT�j
DRY
SERIAL
WATER
AIR
AIR.
TEST ,
OPERATED
MAKE
MODEL
NO.
Q. 0. D.
Q.Ok
P R E 5 S.
PRESS.
PRESS.
OUTLET
PROP ERLY
PIPE
VALVES
MIN.
SEC.
C.
PSI
PSI
PSI
MIN.
SEC
YES NO
17
o 317
1
1 X
IF NO, jXPLAIN
OPERATION PNEUMATIC = ELECTRIC HYDRAULIC
PIPING SUPERVISED YES = NO DETECTING MEDIA SUPERVISED YES NO
D E
DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STA�IONSI YES NO
IS THERE AN ACCESSIBLE FAC.!L,T`, IN EACH CIRCUIT FOR IF-51ING?
YES N 0 F—I
qEIG
IF NO, EXPLAIN
P TION
Does each circ u it oferate
Does each circuit rrate
Maximum time to
ALVES
iI
MAKE
MODEL
Supervision loss a arm?
valve release.
operate release
YES
NO
NO
MIN.
SEC._
ALL P=NG HYDROSTATICALLY TESTED AT PSI FOR�� -HOURS
DRY,P P NG PNEUMATfCALLY TESTED YES NO =
TESTS
EQU PMAN7 OPERATE PROPERLY
YES NO =
IF NO, S TATE REASON
Drain Test: Reading ot gage locatatti nger$svalee��pe Residual pressure with valve in t2tt"pen ide,
S C Ur psi psi
BLANK TESTING
NUMBER
LOCATIONS NUMBER REMCVrb
GASKETS
WELDED OR
IF YES�, 00 YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT THE WELDERS OR BRAZERS ARE QUALIFIED FOR
BRAZED PIPING
WELDING OR BRAZING IN ACCORDANCE WITH THE REQUIREMENTS OF ASME BOILER AND PRESSURE VESSEL CODE.
YeSA� No
SECTION IX. QUALIFICATION STANDARD FOR WELDING AND BRAZING PROCEDURES, WELDERS. BRAZERS, AND
WELDING AND BRAZING OPERATORS - 19eB EDITION. YES IN NO
DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN
REMARKS
) P vf- t e/' / L7 r/ I
NAME OF SPRINKLER (fON7RACTOR F
OR ROPERTY OWNER 151 D TITLE
3<
�q7o oT*-, 5,RA1AJA'LU C4R"'
- # I
I
Aii.—e*t A.
I
PART "C'
--
FOR SPRI,-4.KLER CONTRACTOR (SIGNED)
SIGNATURES
TESTS Wil ED ey li_-� TITLE
DATE
7; rr�,-"r
47W
4