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2006, 07-05 Bldg A - H, J: Material & Test Report for Aboveground PipingA PATRIOT Fire Sprinklers Save Lives! 10005 East Montgomery Spokane, 99206 Email: spoka kane9patriotliro.com FIRE PROTECTION, INC. TEL: (509) 926.3428 FAX: (509) 926.3706 LETTER OF TRANSMITTAL TO Spokane Valley l=ire Dept. 10319 E. Sprague Ave Spokane Valley, WA 99206 WE ARE SENDING YOU THE FOLLOWING Attached Submittals Shop drawings El Copy of letter © Change order DATE: 7I5f2006 AT TH: Fire Marshall Joe 110. RE` Woodruff Apartments 10009 E. 7th Ave! Spokane Valley, WA Go l S. Lt.P - El Samples (OUQSQe'�t 1`�) © V COPIES DATE: NO. DE=SCRIPTION 1 ea Contractors Material & Test Report for Aboveground Piping__ THESE ARE TRANSMITTED as checked below: For approval Ej For review & comment For your use 0 For Your Records REMARKS cc: 0 As requested Thank you SINCERELY Patriot Fire Protection SIGNED: L:4L 1 d � au""o Lorraine Council, Svc Admin VANCOUVER, WA OFFICE TACOMA, WA OFFICE TEL (360) 699.4403 HANFORD, WA OFFICE TEL: (253) 926.2290 PORTLAND (503) 222.6001 TEL (509) 3716695 FAX: (253) 922.6150 FAX (360) 699.4485 FAX (509) 37,1.89 19 - PATRIFP099CF PATRIOT I FIRE PROTECTION CONTRACTORS MATERIAL & TEST REPORT FOR ABOVEGROUND PIPING Upon completion of work, Inspection and tests shall be made by1he contractor's representative and witnessed by an owner's representative. Al defects shall be oorrWod and system left In service before contraclot's personnel finally leave the job. A carOlicate "It be filled out and sign ad by both representatives, Copies shall be prepared for approving authorities, owners, and contractor. Nisunder- stood the owner's representative's signature In noway prejudices any claim against contractor for faulty material, poor workmanship, or failure to comply with approving authority's requirerrients or local ordinanoes, PROPERTY ADDRESS 1466'1 -7L6- PLANS EQUIPMENT USED IS APPROVED' 01fS Q NO I IF NO, EXPLAIN DEVIATIONS * MEASURED FROM TIME INSPECTORS TEST CONNECTION IS 0P�NED ---- --- 85A 1� ; " - (OVER) HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION LWYES UNO OF CONTROL VALVE AND WE AND MAINTENANCE OF THIS NEW EQUIPMENT? IF NO, EXPLAIN HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES: ES NO INSTRU=ONS 1. SYSTEM COMPONENTS INSTRUCTIONS ES NO 2, CARE AND MAINTENANCE INSTRUCTIONS. WES ❑ NO 3. NFPA 13A EKES D NO 61 LOCATION OF SYSTEM SYSTEM Z SERVES: # - - YEAR OF ORIFICE TEMPERAT URE MAKE MODEL MANUFACTURE SLZE QU TY RATING 64 166 4ex �gjljD�_— xi� SPRINKLERS PIPE ANO TYPE OF PIPE ve- F[TTINGS TYPE OF FITTINGS - 02 Zle6 lk=!, e-, ALARM VALVE ALARM DEVICE MAXIMUM TIME TO OPERATE THROUGH TEST CONNECTION TYPE MAKV MIN OR FLOW INDICATOR DRY VALVE MAKE MODEL I SERIAL NO. MAKE MODEL SERIAL NO. TIME TO TRIP • TIME= ALARM DRY PIPE THRU TEST WATER AIR TRIP POINT REACHED OPERATED OPERATING CONNECTION PRESSURE PRESSURE AIR PRESSURE TEST OUTLET PROPERLY TEST MIN. SEC, PSI PSI PSI MIN. SEC. YES �—NO WITHOUT O.O.D. -------- -- WITH x v. �4 IF NO. EXPLAIN k J :7S * MEASURED FROM TIME INSPECTORS TEST CONNECTION IS 0P�NED ---- --- 85A 1� ; " - (OVER) PNEUMATIC U ELECTRIC U HYDRAULIC DELUGE & rnl ., I rvn VALVES/ IS THERE AN ACCESSIBLE FACILITY-IN EACH CIRCUIT FOR TESTING i OYES 0 N IF NO, EXPLAJN DOES EACH CIRCUIT OPERATE DOES EACH CIRCUIT MAXJMUM TIME TO MAKE MODE. SUPERVISION LOSS ALARM OPERATE VALVE RELEASE OPERATE RELEASE YES I NFJ YES NU MIN TEST DESCRIPTION HYDROSTATM: Hydrostatic tests shall be made at not less than 200 psi (13.8 bars) for two hours or 50 psi (3.4 bars) above static pressure In excess of ISO p (10.2 bars) for lw'o hours. Differential` dry -pipe valve clappers shall be lest open during test to prevent damage. All above ground piping leakage shall be steeps. PNEUMATIC: Establish 40 psi (2-7 bars) air pressure and measure drop which shaft not exceed 1•14 psi (0.1 bars) In 24 hours. Test pressure tanks at normal wat, tevel and a1r pressure and measure olr pressure drop which shall not exceed 1'h psi (0.1 bars) In 24 hours. r� 1ZGi( ! PIPING HYDROSTATIC-ALLY TESTED AT V SI FOR HR DRY PIPING PNEUMATICALLY TESTED YES ❑ NO 'EQUIPMENT OPERATES PROPERLY OYES ❑ NO IF 95, §TATE REASON DO YOU CERTIFY AS THE.SPRINKLER SYSTEM CONTRACTOR THAT ADDITIVES AND CORROSIVE CHEMICALS, SODIUM SILICATE OR DERIVATIVES OF SODIUM SILICATE, BRINE, OR OTHER CORROSIVE CHEMICALS WERE NOT USED FOR TEST- ING SYSTEMS OR STOPPING LEAKS? []YES ❑NO. TEST$ DRAIN ST I READING OF U5E LOCATED NEAR WA 9A tI SUPPLY TEST NNECTION; PSI RESIDUAL PRESSURE WITH VALVE IN TEST CONNECTION OPEN WIDE (vC' PSI UNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE! CONNECTION MADE TO SPRINKLER PIPING. VERIFIED BY COPY OF THE U FORM NO.8513 ❑YES ❑ NO OTHER EXPLAIN FLUSHED BY INSTALLER OF UNDER GROUND SPRINKLER PIPING ❑YES Q NO BLANK TESTING NUMBER, USED LOCATIONS NUMBER REMOVED GASKEU WELDED PIPING YES RINO IF YES.. . DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY WIT H THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR- OYES' ONO DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED IN WELDING COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL ARC ❑ YES ❑ NO DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A DOCUMENTED QUALITY CONTROL PROCEDURE TO INSURE THAT ALL DISCS ARE RETRIEVED, THAT OPENINGS IN PIPING ARE SMOOTH, THAT SLAG AND OTHER WELDING RESIDUE ARE REMOVED, AND TE-IAT THE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED OYES . ONO CUTOUTS DO YOU GERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL, DISCS CUTOUTS (DISCS) ARE RETRIEVED? ❑YES ONO FUNCTIONAL DOES AHJ REQUIRE A FUNCTIONAL FLOW TEST OF RESIDENTIAL SPRINKLERS? UyEs 0 FLOWTEST WERE FUNCTIONAL FLOW TEST RESULTS SATISFACTORY? ❑ YES E3 NO HYDRAULIC NAME PLATE PROVIDED IF NO, EXPLAIN DATA NAMEPLATE ES ONO REMARKS DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPE N NAME OF SP CANT TO�i CONTRACTOR LICENSE # =2 �'` PATRIFPO99CF TESTS WITNESSED BY SIGNATURES FOR PROPERTY OWNER (SIGNED) TITLE DATE - FOR SPRIVM51T92 7 DATE FOR APPROVE G H PITY TITLE DATE I CERTIFY THAT THE INFORWT1911HE REIN IS TRUE AND THAT THIS SPRINKLER SYSTEM WAS INSTALLED IN ACCORD - 8- CE WITH RCW 1 &160 AND - ULES ADOPTED BY THE WAS7N ADM INIST TIVE CODE AS ADMINISTERED BY CERTIFICATION HE STATE FIRE MARSHAL 1l + be. p� }fit t- oW+J NA? E rA O��GO NOY HOLfJER (PRINT OR TYPE) I-ep 4 Lod Qf {T MRA GUMFiCATEOFCOMPETENCY - CERTIFICATE REGISTRATION DATEiJ OG a M H7 _610. PATRIOT I FIRE PROTECTION CONTRACTORS MATERIAL & TEST REPORT FOR ABOVEGROUND PIPING Upon oompleflon of work, Inspedon and tests aball be made by the contractor's representative and witnessed by an owner's representative. All defects she be corfedtad and system left In service before contractor's personnel finally leave the job. A cortifloate shall be filled out and signed by bqth representatives. Copies shall be prepared for approving authorities, owners, and contractor. his under- stood the owner's repre aentative's signature inn no way prejud loss any claim ag al n at oonttactor for faulty material, poor workmanship, or failure to comply with approving authority's requIrarrients or local ardinanoes. PROPERTY ADDRESS ?J66 q `7 k4f)ya- T PLANS EQUIPMENT USED ($ APPROVED IF NO, EXPLAIN DEVIATIONS osr NO' INSTRUCTIONS HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED'AS TO LOCATION WYES LJ NO OF CONTROL VALVE AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT? IF NO, EXPLAIN HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES: 1 A YES NO 1, SYSTEM COMPONENTS INSTRUCTIONS M�ES ONO Z CAREAND . MAINTENANCE INST5UCTi0N$. ZYES ONO 3. NFPA 13A I&YES [3NO 4?1 LOCATION Of SYSTEM SYSTEM SERVES: 15 d SPRINKLERS MAKE MODEL YEAR OF MANUFACTURE ORIFICE Slzrz QUANTITY TEMPERATURE RATING ay PIPE AND FITTINGS TYPE OF PIPE 6h 61 TYPE OF FITTING S r - ALARM VALVE OR FLOW INDICATOR ALARM DEVICE MAXIMUM TIME TO OPERATE THROUGH TEST CONNECTION TYPE MODEL MIN SEC. -,%a 4 T1_ DRY PIPE OPERATING TEST DRY VALVE O.OD, MAKE MODEL I SERIAI.NO. MAKE MODEL SERIAL NO, TIME TO TRIP THRU TEST CONNECTION WATER PRESSURE AIR PRESSURE TRIP POINT AIR PRESSURE TIME WATER R H TLET ____ALkRM OPERATED PROPERLY MIN, SEC. psi PSI PSI MIN. SEC. YES I NO WITHOUT O.O.D. V� WITH Q.O.D fai W, it- NU, * MEASURED 85A (OVER) ,11 )PENED (OVER) ,11 HUUIIK]NAL EXF'tiSNATIDN AND 7tOTE$ �p W 8RC.K '!V OPERATION ❑ PNEUMATIC ❑ IELECTRIC ❑ HYDRAULIC DELUGE & PPEACTION VALVE PIPING SUPERVISED YES NO DETECTING MEDIA SUPERVISED YES NO DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATIONS LIYES NO IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT FOR TESTING I ❑YES ❑NO IF NO, EXPLAIN DOES EACH CIRCUIT OPERATE DOES EACH CIRCUIT MA7(1MUM TIME TO MAKE MODEL SUPERVISION LOSS ALARM OPERATE VALVE'. RELEASE OPERATE RELEASE TEST DESCRIPTION HYDROSTATIC: Hydrostatic tests shag be made at not less Than 200 psi (13.8 barsl for two hours or 50 psi (3.4 bars) above slatio pressure In excess of 150p (10'2 bans) for two hours. Wferential dry-pipe valve clappers shall be left open during test to prevent damage. Alt above ground piping leakage shall be steppe PNlrtll,SATIC: Establish 40 psi (2.7 bars) air pressure and measure drop which shall not exceed 1•y, ps1(0.1 bars) In 24 hours. Test pressure tanks at normal wab level and air pressure and measure air pressure drop which shall not exceed 11/2 psi (0.1 bars) In 24 hours. �. ALL PIPING HYDROSTATICALLY TESTED AT PSI FOR HRS. OW PIPING PNEUMATICALLY TESTED ES ❑NO EQUIPMENT OPERATES PROPERLY " ❑ YES ❑ NO IF NO, AE REASON f a A / iY DO YOU CERTIFY AS THE SPRINKLER SYSTEM CONTRACTOR THAT ADDITIVES AND CORROSIVE CHEMICALS, SODIUM SILICATE OR DERIVATIVES OF SODIUM SILICATE, BRINE, OR OTHER CORROSIVE CHEMICALS WERE NOT USED FOR TEST- ING SYSTEMS OR STOPPING LEAKS? ❑YES . ONO TESTS DRAIN ST I I I 7AMEADING OF QAGE LO TED NEAR WATER 4 SUPPLY TEST CONNECTION; PSI RESIDUAL PRESSURE NTH VALVE IN TEST CONNECTION OPEN WIDE 65 PSI UNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE TO SPRINKLER PIPING. RIFTED BY COPY OF THE U FORM NO. 8513 OYES ❑ NO OTHER EXPLAIN FLUSHED BY INSTALLER OF UNDER- GROUND SPRINKLER PIPING ❑YES ❑ NO BLANK TESTING NUMBER U ED LOCATIONS NUMBER REMOVED GASKETS LCE PIPING MYES Nf0 IF YES.. . DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY H THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL ARC ❑ YES - 0 NO WELDING DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS DI 0.9, LEVELAAti3 ❑ YES ❑ NO DO YOU CERTIFY THAT WELDING WAS CARRIED OUT INCOMPLIANCE WITH A DOCUMENTED QUALITY CONTROL PROCEDURE TO INSURE THAT ALL DISCS ARE RETRIEVED, THAT - OPENINGS IN PIPING ARE SMOOTH, THAT SLAG AND OTHER WELDING RESIDUE ARE REMOVED, AND THAT THE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED OYES ONO CUTOUTS _ _ D© YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL DISCS CUTOUTS ISCS ARE RETRIEVED? DYES ONO FUNCTIONAL FLOWTEST DOES AHJ-REQUIRE A FUNCTIONAL FLOW TEST OF-RESIDENTIAL SPRINKLERS? UYES LJNO WERE FUNCTIONAL FLOW TEST RESULTS SATISFACTORY? ❑ YES ❑ NO HYDRAULIC NAME PLATE PROVIDED IF NO, EXPLAIN DATA NAMEPLATE ES ❑NO REMARKS DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: -��� NAME OF SPRINKLER CTOR r . CONTRACTOR LICENSE # h PATRIFP099CF TESTS WITNESSED BY SIGNATURES FOR PROPERTY OWNER (SIGNED) TITLE DATE - FOR SPRINKLE {SIGN TIT DATE �ul FQR APPROVI THfl TTY LE �? / r1A`_ "EIN '2 -. ;2 I CERTIFY T T THE INFOR IS TRUE AND THAT THIS SPRINKLER SYSTEM WAS INSTALLED IN ACCORD. CE WITH ROW 45-160 AND TH�'RULES ADOPTED BY THE WASHI TON ADMINIST CEDE AS ADMINISTERED BY CERTIFICATION tIVE HE STATE FIRE MARSHAL A &U i b 2/Ltvt- i J -AWS ism NAME OF CE rAT'E QE 2OM"NOY HOWER (PRINT OR TYPE) WNA OF CERTIFICATE OF COMPETENCY HOLM CERTIFICATE REGISTRATION # DATEta 4 HUUIIK]NAL EXF'tiSNATIDN AND 7tOTE$ �p W 8RC.K '!V ri ff -RIC 97 /� CONTRACTORS MATERIAL & TEST REPORT FOR ABOVEGROUND PIPING PROCEDURE.,.... M ...................... m.......... �......... T...,............,.... r... �. mm� ....�.............�...,._....�. �. �..........,... �................... m.............". �m .�..,.............r�.,......... Upon completion of work, Inspection and tests shall be made by the contractor's representative and witnessed by an owner's ropresontat[vat All defects shall be corrected and system left In service before contractor's personnel finally leave the job. A certificate shall be filled out and slg nod by both repro sentatives. Copies shall be prepared for approving authorities, owners, and contractor, it Is under- stood the owner's representative's aignature in noway prejudices any claim against contractor for faulty matorial, poor workmanship, or failure to comply with approving authority's requlrerrents or local ordinances. rnvrcn, , own" &) �y dA 1 r • - I uni G..1.� �� PROPERTY ADDRESS U 0 C�� �l r� % )Z>bq ' MEASURED FROM TIME INSPECTORS TEST CONNEUTIUN IS UVENtU. 85A _ (OVER) ACCEPTED -BY APPROVING AUTHORITIES (NAME) �. ADDRESS PLANS'. INSTALLATION CONFORMS TO ACCEPTED PLANS EQUIPMENT USEDJS APPROVED NO DNO IF NO, EXPLAIN DEVIATIONS HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION 5Y ES ONO OF CONTROL VALVE AND CARE ANO MAINTENANCE OF THIS NEW EQUIPMENT? IF NO, EXPLAIN HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES: ES NO INSTRUCTIONS 1. SYSTEM COMPONENTS INSTRUCTIONS 2. CARE AND MAINTENANCE INSTRUCTION_ & ES ❑ NO FES: ❑ NO 3. NFPA 13A AYES ONO LOCATION OF SYSTEM SYSTEM a SERVES; YEAR OF R! ICE TEMPERATURE MAKE MODEL MANUFACTURE ZE QUANTITY RATING SPRINKLERS .� . a PIPE AND FITTINGS TYPE OF PIPE �^ 10V C- TYPE OF FITTINGS c. ALARM ALARM DEVICE MAXIMUM TIME TO OPERATE VALVE THROUGH TEST CONNECTION TYPE - E MODEL - MIN SEC. OR FLOW - INDICATOR DRY VALVE =D. MAKE I MODEL I SERIAL NO, MAKE MODEL SERIAL NO. • TIME TO TRIP " TIME WATER ALARM DRY PIPE THRU TEST WATER AIR TRIP POINT REACHED OPERATED OPERATING CONNECTION PRESSURE PRESSURE AIR PRESSURE TEST OUTLET PROPERLY TEST MIN. SEC. PSI at ,s ::,pS( PSI MIN. SEC. YE WITHOUT O.O.D. WITH As Q.O.D. IF N N v �1 ' MEASURED FROM TIME INSPECTORS TEST CONNEUTIUN IS UVENtU. 85A _ (OVER) rn A4 t Ivrr VA VES IS THERE AN ACCESSIBLE FACILITY-IN EACH CIRCUIT FOR TESTING DYES [I NO IF NO, EXPLAIN DOES EACH CIRCUIT OPERATE DOES EACH CIRCUIT MAXIMUM TIME TO— MAKE MODEL SUPERVISION LOSS ALARM OPERATE VALVE RELEASE OPERATE RELEASE TEST DESCRIPTION TES HYDROSTATIC: Hydrootado tests shall bo made at not less then 200 ps€ (19:8 bars) for two hours or 50 psi (3A bars) above static pressure in excess of 150p (10.2 bars) for two hours. Differential dry-pipe valve clappers shat{ be left open during test to prevent damage. All above ground piping leakage shall be sloppe PNEUMATIC EstabiIsh 40 psi i2.7 bars} air pressure and measure drop which shall not exceed 1-1/2 psi (0.1 bars) In 24 hours, Test pressure tanks at normal wat, level and air pressure and measure air pressure drop which shall not exceed 1% psi (0.1 bars) In 24 hours. C7 jq�fict WeX All PIPING MROSTATICALLY TE5TF-L)AJr;CJ1Z PSI FQR_jy,_HR6- DRY PIPING PNEUMATICALLY TESTED OYES ❑ NO EQUIPMENT OPERATES PROPERLY ❑YES ONO H- NO, STATE REASON !! UO YOU CERTIFY AS THE.SPRINKLER SYSTEM CONTRACTOR THAT ADDITIVES AND CORROSIVE CHEMICALS, SODIUM SILICATE OR DERNATNES OF SODIUM SILICATE, BRINE, OR OTHER CORROSIVE CHEMICALS WERE NOT USED FOR TEST. ING SYSTEMS OR STOPPING LEAKS? ❑YES _ ONO TESTS DRAIN READING OF NGE 16517TED NEAR WATER RESIDUAL PRESSURE WITH VALVE IN TEST ST SUPPLY TEST CONNECTION: PSI CONNECTION OPEN WIDE PSI UNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE TO'�� SPRINKLER PIPING. VERIFIED BY COPY OF THE U FORM N0.858 OYES ❑ NO OTHER EXPLAIN FLUSHED BY INSTALLER OF UNDER- GROUND SPRINKLER PIPING ❑YES ❑ NO BLANKTESTINQ NUMBER SED LOCATIONS NU�dBER REMOVED QASKETS WELDED PIPING LJYES Mo IF YES.. . DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY H THE REQUIREMENTS OF AT LEAST AWS 1019.9, LEVEL AR3 ❑ YES ❑ NO WELDING DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR-3 ❑ YES ❑ NO DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE W TH A DOCUMENTED QUALITY CONTROL PROCEDURE TO INSURE THAT ALL DISCS ARE RETRIEVED, THAT OPENINGS IN PIPING ARE SMOOTH, THAT SLAG AND OTHER WELDING RESIDUE ARE REMOVED, AND THAT THE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED DYES ❑ NO CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL DISCS CUTOUTS DISCS ARE RETRIEVED? DYES ❑NO FUNCTIONAL FLOWTEST DOES AHJ REQUIRE A FUNCTIONAL FLOW TEST. OF RESIDENTIAL SPRINKLERS? DYES 0 WERE FUNCTIONAL FLOW TEST RESULTS SATISFACTORY? ❑ YES pin NAME PLATE PROVIDED IF NO, DCPLAIN DATA NAMEPLATE ES ONO I REMARKS DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: Zoe' NAME OF SPRI CONT CTO _ CONTRACTOR LICENSE x PATRIFP099CF TESTS WITNESSED BY SIGNATURES FOR PROPERTY OWNER (SIGNED) TITLE DATE FOR SffI1We4ILCQNTWTO T T ' DATE FOR APPROVING AUTHORITY TITLE DATE I CERTIFY THAT THE INFORMATION HEREIN IS TRUE AND THAT THIS SPRINKLER SYSTEM WAS INSTALLED IN ACCORD• CERTIFICATION E WITH RCW 18.169 AND THE RULES 110 BY THE WASH NGTON TIV ADMINIST E CODE AS ADMINISTERED BY HE STATE FIRE MARSHAL fr NAME CF CEAWrAlt O OD NGY HOLDER (PRINT (on TYPhl 0 WHA CERnF TE OF OOMPEM40Y HO[DE David He"-m= CERTIFICATE REGISTRATION # rs DATE Q eM BACK PATRIOT FIRE PROTECTION ��{{ CONTRACTORS MATERIAL & TEST REPORT FOR ABOVEGROUND PIPING PROCEDURE Upon completion of work, Inspection and tests shall be made by the contractor's representative and witnessed by an owner's representative, All defects shell be oor(acted and system left in service before contractor's personnel finally leave the Job. A certificate sha11 be filled out and signed by both representatives. Copies shall be prepared for approving authorities, owners, and contractor, his under. stood the owner's representative's signature in noway prejudices any claim against contractor for faulty material, poor workmanship, or fallure to comply with approving authority's requirements or local ordinances. PROPERTY NAM E (� / %I` I DATE — PROPERTY ADDRESS n+W,, ) 0 314 " F S I~ INSTALLATION CONFORMS TO ACCEPTED-PLANS MES NO PLANS EQUIPMENT USED IS APPROVED n-frS' 0 NO IF NO, EXPLAIN DEVIATIONS INSTRUCTIONS HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION YES ETNO OF CONTROL VALVE AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT? IF NO, EXPLAIN HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES: ES NO 2. SYSTEM COMPONENTS INSTRUCTIONS ES [I NO 2. CARE AND MAINTENANCE INSTRUCTIONS, C&YES ONO 3. NFPA 13A ES ❑ NO LOCATION OF SYSTEM ` ! SYSTEM # f S SERVES: 4 al .f�1 " SPRINKLERS MAKE MODEL YEAR OF MANUFACTURE ORIFICE StZE QUANTITY TEMPERATURE RATING 4f r —a PIPE AND FITTINQS TYPE 'OF PIPE TYPEOF FITTINGS ALARM VALVE OR FLOW INDICATOR ALARM DEVICE MAXIMUM TIME TO OPERATE THROUGH TEST CONNECTION TYPE MAKE MODEL MIN SEC. DRY PIPE OPERATING TEST DRY VALVE Q.OD. MAKE MODEL SERIAL NO, MAKE I MODEL_._ _ SERIAL NO, -- • TIME TO TRIP THRU TEST CONNECTION WATER PRESSURE AIR PRESSURE TRIP POINT AIR PRESSURE ' TIME WATER REACHED TEST OUTLET ALARM OPERATED PROPERLY MIN. SEC, PSI PSI PSI MIN, SEC. YES I NQ— WITHOUT O.O.D. WITH r h ,� 177- P IF N N t; �-y- 'ML-ASUHED FROM TIME INSPLUIUKS IE:bI UUNNtl,IlUrvlbUrervrv.r 85A 'k t> (OVER) d rnriku l l " VALVES IS THERE JAC BLE FACLffY IN EACH CIRCUIT FOR TESTING 1F E$--'- Q NO N0, EXPLAIN DOES EACH CIRCUIT OPERATE DOES EACH CIRCUIT MAXIMUM TIME TO MAKE MODEL. SUPERVISION LOSS ALARM OPERATE VALVE RELEASE OPERATE RELEASE TEST DESCRIPTION HYDROSTATIC; Hydroslahc tests shall be made at not less than 200 psl (13.8 bars) for two hours or 50 psi (3.4 bars) above static pressure In excess of 1E0 p (10.2 bars( for two hours. Differential dry -pipe valve clappers shall be left open during test to prevent damage. All above ground piping leakage shall he sfoppe PNEUMATIQ Establlsh40 psi (2.7 bars) air pressure and measure drop which shall not exceed 1 -11, psi (0.1 bars) In 24 hours. Test pressure tanks at normal wat+ level and air pressure and measure air pressure drop whlch sh II not exceed 1f, psi (0.1 bars) In 24 hours. — ° r PIPING RVOR TATI Y TESTED AT P t HR .. Na� ❑O EQUIPMENT OP>RATES PROPERLY DYES ONO IF , ATE REASON DO YOU CERTIFY AS THE.SPRINKLER SYSTEM CONTRACTOR THAT ADDITIVES AND CORROSIVE CHEMICALS, SODIUM SILICATE OR DERIVATIVES OF SODIUM SILICATE, BRINE, OR OTHER CORROSLVE CHEMICALS WERE NOT USED FOR TEST- ING SYSTEMS OR STOPPING LEAKS? DYES ❑NO TESTS DRAIN ST READING OF GE TED NEAR ATER RESIDUAL PRESSURE WITH VALVE INTEST SUPPLY TEST CONNECTION; '7 PSI CONNECTION OPEN WADE (p PSI UNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE TO SPRINKLER PIPING. VERIFIED BY COPY OF THE U FORM NO. 85B ❑YES ❑ NO OTHER EXPLAIN FLUSHED BY INSTALLER OF UNDER- GROUND SPRINKLER PIPING ❑YES ❑ NO BLANK TESTING NUMBER U EO LOCATIONS NUMBER REMOVED GASKETS LDE PIPING LJYES NO IFYES. , . 00 YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL ARC ❑ YES 0 NO DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED IN WELD[NLA COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS 010.9, LEVEL AI ❑ YES ❑ NO DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLANCE WITH A DOCUMENTED QUALITY CONTROL PROCEDURE TO INSURE THAT ALL DISCS ARE RETRIEVED, THAT OPENINGS IN PIPING ARE SMOOTH; THAT SLAG AND OTHER WELDING RESIDUE ARE REMOVED, AND THAT THE INTERNAL DIAMETERS OF PIPING AhE NOT PENETRATED OYES ❑ NO CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL DISCS CUTOUTS DISCS ARE RETRIEVED? ❑ YES - EI O FUNCTIONAL FLOWTEST DOES AHJ REQUIRE A FUNCTIONAL FLOW TEST OF RESIDENTIAL. SPRINKLERS? LJ YES O WERE FUNCTIONAL FLOW TEST RESULTS SATISFACTORY? ❑YES ❑ NO NAME PLATE PROVIDED IF NO, EXPLAIN DATA NAMEPLATE YES 0 N DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN, REMARKS NAME OF SPRI CONIVACTO 7 R F` 4 t3 i cy rte^- CONTRACTOR LICENSE a PATSIFP0990F TESTS WITNESSED BY SIGNATURES FOR PROPERTY OWNER (SIG NE D) TITLE DATE- 4 1 1 FO ONT I _. EDL4 L DATEr �} --cac U ­4 FOR APPROVING AUTHO TI LE HATE _s � I CERTIFY THAT THE INF TION HEREIN IS TRUE AND THAT THIS SPRINKLER SYSTEM WAS INSTALLED IN ACCORD• CE WITH RCW 18-160 D THE RULES ADOPTED BY THE WAS TON ADMINIS T NE CODE AS ADMINISTERED BY CERTIFICATION HE STATE FIRE MARSHAL } ,�' iy r , *J Qom'" NAM C FIGAXE I NOYFIOLDFR(PRiNTORTYPE) 4 5* OF CERTIFICATE OF oompmNCY HOLDEK CERTIFICATE REGISTRATIO DATE (, 0L"_ David 11"rmmn MATRI ®T FIRE PROTECTION CONTRACTORS MATERIAL & TEST REPORT FOR ABOVEGROUND PIPING PROCEDURE Upon oompietion of work, Inspection and tests shall be made by the contractor's representative and witnessed by an owner's representative. All defecis shall be corredted and system left in service before contractor's personnel finally leave the Job. Acertificate shall be filled out and signed by both representatives..Copies shall be prepared for approving authorities, owners, and contractor. ltls under. stood the owner's, representative's signature in noway prejudices any claim against contractor for faulty material, poor workmanship, of failure to comply with approving authority's requlren ants or local ordinances. FKUFhKIT r WIZ // J�U _f i uNIC q-zo -0�) PLATS I EQUIPMENT USED IS APPROVED UIE' $ I] NO IF NO, EXPLAIN DEVIATIONS MEASURED FROM TIME INSPECTORS TEST CONNECTION 1S OPENED`.,,- • 85A _ (OVER) HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION � ES LINO OF CONTROL VALVE AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT? IF NO, EXPLAIN HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES' YES: UNO INSTRUCTIONS 1. SYSTEM COMPONENTS INSTRUCTIONS YES ONO 2. CARE AND MAINTENANCE INSTRUCTIONS, YES ❑NO 3. NFPA 13A YES NO LOCATION OF SYSTEM ` SYSTEM x SERVES: &V1 cJ /, YEAR OF ORIFICE TEMPERATURE Mwe MODEL MANUFACTURE SIZE QUANTITY RATING ., `p 4 SPRINKLERS i u PIPE AND FITTINGS TYPE OF PIPE Oe TYPE OF FITTINGS ALARM ALARM DEVICE MAXIMUM TIME TO OPERATE VALVE THROUGH TEST CONNECTION TYPE 4 ME MODEL MIN SEC. OR FLOW - -+ as INDICATOR DRY VALVE Q.OD. MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO. " TIME TO TRIP ' TIME WATER AMM DRY PIPE THRU TEST WATER AIR TRIP POINT REACHED OPERATED OPERATING CONNECTION PRESSURE PRESSURE AIR PRESSURE TEST OUTLET PROPERLY TEST MIN, SEC. PSI PSI MIN. SEC. YES NO WITHOUT O.O.D. f - J? 5 f ,. V.} WITH,f Q.O,D, ,k , IF No, EXPLAt :+ S ' MEASURED FROM TIME INSPECTORS TEST CONNECTION 1S OPENED`.,,- • 85A _ (OVER) TION DELUGE it TRIP AND /OR VA`L IS THERE AN SSIBLE FACILITY IN EACH CIRCUIT FOR TESTING I OYES ONO IF NO, EXPLAIN \ DOES EACH CIRCUIT OPERATE DOES EACH CIRCUIT MAXIMUM TIME TO MAKE MODEL SUPERVISION LOSS ALARM OPERATE VALVE RELEASE OPERATE RELEASE YES I NO TEST DESCRIPTION HYDROSTATIC: Hydrostatic tests shall be made at not less than 200 psi (13.9 bars) for two hours or 60 psi (3.4 bars) above stallo pressure In exooss of 150 p (10.2 bars) for two hours. Differential dry -plpe valve clappers shalt be left open during test to prevent damage. Ali above ground piping leakage shall be stoppe, PNEUMATIC: EstabTish 40 psi (2,7 bars) air pressure measure drop which shall not exceed 1.1/i psi (0.1 bars) In 24 hours. Test pressure tanks at normal wat, level and air pressure and measure air pressure drop which s II not exceed 1Y psi (0.t bars) in 24 hours. a Q� PIPING DR TATI Y TE TED AT PSI FOR d HRS. DRY PIP ING PNEUMATICALLY TEST ED YES LINO IF NO, STATE RU SON EQUIPMENT OPERATES PROPERLY ❑YES 0 N DO YOU CERTIFY AS THE.SPRINKLER SYSTEM CONTRACTOR THAT ADDITIVES AND CORROSIVE CHEMICALS, SODIUM SILICATE OR DERIVATIVES OF SODIUM SILICATE, BRINE, OR OTHER CORROSIVE CHEMICALS WERE HOT USED FOR TEST- ING SYSTEMS OR STOPPING LEAKS? ❑YES [INC) TESTS DRAIN READING F GAGE L TED NEAR WATER RE IDUAL PRESSURE VATH VALVE IN TEST ST SUPPLY TEST CONNECTION: PSI CONNECTION OPEN WIDE psi UNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE TO SPRINKLER PIPING, RIFTED BY COPY OFTHE U FORM N0.95B DYES 0 N OTHER EXPLAIN FLUSHED BY INSTALLER OF UNDER- ROUND SPRINKLER PIPING ❑YES ❑ NO BLANK TESTING NUMB USED LOCATIONS NUMBER REMOVED GASKETS WELDED PIPING YES O IF YES... DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY WITH THE REQUIREMENTS OF AT LEAST AWS 010.9, LEVEL A" ❑ YES ❑ NO WELDING DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR-3 ❑ YES ❑ NO DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A DOCUMENTED QUALITY CONTROL PROCEDURE TO INSURE THAT ALL DISCS ARE RETRIEVED, THAT OPENINGS IN PIPING ARE SMOOTH, THAT SLAG AND OTHER WELDING RESIDUE ARE REMOVED, AND THAT THE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED ❑YES ONO CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL DISCS CUTOUTS (DISCS) ARE RETRIEVED? ❑YES ❑NO FUNCTIONAL FLOWTEST DOES AHJ REQUIRE A FUNCTIONAL FLOW TEST OF RESIOENTOL SPRINKLERS? UYES tANO WERE FUNCTIONAL FLOW TEST RESULTS SATISFACTORY? ❑YES • NO HYDRAULIC DATA NAMEPLATE NAME PLATE PROVIDED OXES ❑NO IF NO, EXPLAIN REMARKS DATE LEFT IN SERVICE WITH CONTROL VALVES OPEN; r06 NAME OF SPRI NT CTO CONTRACTOR LICENSE a ti`l it ~ PATRIFP0990F TESTS WITNESSED BY SIGNATURES FOR PROPERTY OWNER (SIGNED) TITLE DATE FOR DATE =0 FOR APPROVING AUTHORITY TIT DATE I CERTIFY THAT THE INFORMATION HEREIN IS TRUE AND THAT THIS SPRINKLER SYSTEM WAS INSTALLED IN ACCORD- CERTIFICATION ANCE WITH RCW 18.160 AND THE RULES ADOPTED BY THE WAS GTON ADMINIST THE CODE AS ADMINISTERED BY HE STATE FIRE MARSHAL p� LORI NAME OF FICAIE. CO PErENCY HOLE)ER (PRNT OR TYPE) SIGHA OF CEMFMTE OF COMPETENCY HOLDER CERTIFICATE REGISTRATION DATE PATRIOT FIRE PROTECTION /� CONTRACTORS MATERIAL & TEST REPORT FOR /'' soVEGROUND PIPING PROCEDURE�. � ................... �,... �.._._.._.........._. �..._., �.. �.,..........,,,... �_........,...,.. �. �..................,..........;,..,...,..... �,,.,.,........,,,.., �....... �.. r,..........,......... �. �..... _,..,.........�,.....,.,.,...., Upon oornpletion at work, Inspection and tests shell be made by the contractor's representative and witnessed by an owner's representative, All defectS shall be oorrected and system left in service before contractor's personnel finally leave the job, A certificate shall be filled out and signed by both representatives, Copies shall be prepared for approving authorities, owners, and contractor. his under. stood the owner's representative's signature in noway prejudices any claim against contractor for faulty material, poor workmanship, or failure to comply with approving authority's requironrionts or local ordinanoss. cis— C PROPERTY ADDRESS ` 1ll�l /19 1 47-Z� a, 1 � R rJ E >3t`� 1_. PRr�ctiuE 5po PLANS EQUIPMENT USED IS APPROVED OYES ONO IF NO, EXPLAIN DEVIATIONS (� INSTi CTIOT�S HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION VJYES LJNO OF CONTROL VALVE AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT? IF NO, EXPLAIN HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES: YES : NO t' SYSTEM COMPONENTS INSTRUCTIONS YES ONO 2. CARE AND MAINTENANCE INSTRUCTION_ S. NYE$ ❑NO 3. NFPA 13A JEYES ONO LOCATION OF SYSTEM SYSTEM # I SERVES, SPRINKLERS MAKE MODEL YEAR F MANUFACTURE ORIFICE SIZE QUANTITY TEMPEf ATURE RATING 1h s A7. , PIPE AND FITTINGS TYPE OF PIPE S , 4 11C- TYPE OF FITTINGS ALARM VALVE OR FLOW INDICATOR ALARM DEVICE MAXIMUM TIME TO OPERATE THROUGH TEST CONNECTION TYPE MAKE MODEL . MIN SEC. � DRY PIPE OPERATING TEST j\ T DRY VALVE Q.OD. MAKE I MODEL I SERIAL NO. MAKE I MODEL SERIAL NO. ' TIME T5 TRIP THkU TEST CONNECTION WATER PRESS E AIR PR . 3U '_: TRIP POINT' "Ai ,PRESSURE IM R CHID T OUTLET ALARM OPERATED ROPERLY M SEC. P 4 ` p,Slt:,'.:' `,r`HSI SEC, YES NO WIT OUT . . AIFN EXPLAIN { of :; OPERATION _ 65A BACK o, �0u�b Dece�bp4 LJPNEUM4M UELECTRIC RAULIC DELUGE A PREACTION VALVES PIPING SQP`8J1VSEO UYES NO DETE TING MEDIASUPERV YES 0 DOES V VE OPERATE FROM TAE UAL TRIP AN OR REMOTE CONTROL STATIONS YES N IS THE E AN A CESSIBLE F 1LITY-IN CH CIRC FORTES ❑YES NO NG IF NO, N D0. DOES CH C CUIT OPERATE SUP S LOSS ALARM DOES CH CIRCUIT OP E VALVE RELEASE MUM TI TO OPERATE REL E TEST DESCRIPTION HYDROSTATIC: Hydrostatic tests shall be made at not less than 200 psl (13.8 bars) for two hours or 50 pal (3.4 bard above static pressure In excess of 150 P (10.2 bars) for two hours. Dlfferenllal dry•plpe value clappers shall be left open during test to prevent damage. All above ground plying leakage shall be stoppe, PNEUMATIC: Establish 40 psi (2.7 bara) alr pressure and measure drop which shall not exceed 1-U: psi (0.1 bars) In 24 hours. Test pressure tanks at normal watt level and air pressure and measure air pressure drop which shall not exceed i Sh psi (0.1 hard In 24 hours. �7 0` ;?!kof ALL PIPING HYDROSTATICALLY TESTED AT P F R HAS, DRY PIPING PNEUMATICALLY TESTED 10YES ❑ NO EQUIPMENT OPERATES PROPERLY 2YES ONO I IF NO, SrA—FE 8EASUN DO YOU CERTIFY AS THE.SPRINKLER SYSTEM CONTRACTOR THAT ADDITIVES AND CORROSIVE CHEMICALS, SODIUM SILICATE OR DERIVATIVES OF SODIUM SILICATE, BRINE,.OR OTHER CORROSIVE CHEMICALS WERE NOT USED FOR TEST - ING SYSTEMS OR STOPPING LEAKS? LIRYES ❑ NO TESTS DRAIN READING OF UAGE L TED NEAR WATER RESIDUAL, PRESSURE WITH VALVE IN TEST ST SUPPLY TEST CONNECTION: - .. PSI CONNECTION OPEN WIDE PSI UNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE TO SPRINKLER PIPING. RJFIED 8Y COPY OFTHE U FORM NO.85B OYES ❑ NO OTHER EXPLAIN FLUSHED BY INSTALLER CIF UNDER- GROUND SPRINKLER PIPING ❑YES ❑ NO BLANK TESTING NUMBER USED LOCATIONS NUk4BER REMOVED GASKETS WELDED PIPING " YES P3NO IF YES... DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY H THE REQUIREMENTS OF AT LEAST AWS D10,9, LEVEL AR-3 ❑ YES ❑ NO W E ING DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVELAR3 ❑YES ONO DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A DOCUMENTED QUALITY CONTROL PROCEDURE TO INSURE THAT ALL DISCS ARE RE7RIEVED, THAT OPENINGS IN PIPING ARE SMOOTH,.THAT SLAG AND OTHER WELDING RESIDUE ARE REMOVED, AND THAT THE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED ❑ YES [INC) rr CUTOUTS fR DISCS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL CUTOUTS DISCS ARE RETRIEVED? VYES ELINO FUNCTIONAL FILOWTEST DOES AHJ REQUIRE A FUNCTIONAL FLOW TEST OF RESIDENTIAL SPRINKLERS? UYES WERE FUNCTIONAL FLOW TEST RESULTS SATISFACTORY? ❑YES MNO ESNO DATA NAMEPLATE NAME PLATE PROVIDED IF NO, EXPLAINL ES ONO REMARKS DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN, + NAME OF SPRINKLER CONTRACT Q� ,� CONTRACTOR LICENSE # Y'd-\-V\aa yid { `p(� IPATRIFP099CF TESTS WITNESSED BY SIGNATURES FOR PROPERTY OWNER (SIGNED) TITLE DATE FOR SPRINKLER CONTRACTOR (SIGNED) TITLE DATE FOR PROVING A TITLE ATE U r z I R IFY THAT E" I ORMATION HEREIN IS TRUE AND THAT THIS SPRINKLER SYSTEM WAS INSTALLED IN ACG D- EWITH RCW 1 AND THE RULES ADOPTED BY THE WA INGTON ADMINIS RATNE CODE AS ADMINISTERED BY CERTIFICATION HE STATE FIRE MARSHAL &k A., ) t � N NNAE OF CE SLATE OF ?tP NCY HOLDER (PRINT OR TYPE) WNA E C- 811PICATEOf COMPETENCYHOLDE CERTIFICATE REGISTRATI nat4d Hr DATE L n U 65A BACK o, �0u�b Dece�bp4 PATRIOT FIRE PROTECTION //�� CONTRACTORS MATERIAL & TEST REPORT FOR ABOVEGROUND PIPING PROCEDURE��...... �..-..- �..,.........._ ... ........................::,.�:: -.,..., r.. �,.......... �....._ m....._..,. �......-,.....ti.,,.......,.. m.... m.,, �...,.... ....,.,.......�..mm....,,....., T.,.....,.m.....,.., Upon completion of work, Inspection and tests shell be made by the contractor's representative and witnessed by an owner's representative. All defects shall be oorracted and system left in service before oontfactor'a personnel finally leave the Job. A certificate shell be filled out and signed by both representatives. Copies shall be prepared for approving authorities, owners, and contractor. his under- stood the owner's representative's signature in noway pre]udiose any claim against contractor for faulty material, poor workmanship, or failure to comply with approving authority's requlren ants or local ordlnanc*s. -7 /-eve -P 4' y ij * MEASURED FROM TIME INSPECTORS TEST CONNECTION IS tJPENER, J, 85A �•,�' (OVER) gL� G ACCEPTED BY APPROVING AUTHORITIES (NAME) ADDRESS PLANS INSTALLATION CONFORMS TO ACCEPTED PLANS EQUIPMENT USED IS APPROVED IG�"Y Q N00 ES IF NO, EXPLAIN DEVIATIONS HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION ES NO OF CONTROL VALVE AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT? IF NO, EXPLAIN HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES; 8: NO INSTRUCTIONS t' SYSTEM COMPONENTS INSTRUCTIONS 2, CAREAND MAINTENANCE INSTRUCTIONS. fES ONO Mpff S ❑NO 3. NFPA 13A IIdYES NO LOCATION OF SYSTEM 1 SYSTEM #� .$����fjQt SERVES: — '-'— --� -- YEAR F ORIFICE TEMPERATURE MAKE MODEL MANUFACTURE QUANTITY RATING S SPRINKLERS ' S PIPE AND TYPE OF PIPE L V %atelL-. FITTINGS TYPE OF FITTINGS r1f )",a ALARM � ALARM DEVICE MAXIMUM TIME TO OPERATE VALVE THROUGH TEST CONNECTION TYPE MODEL MIN SEC. OR FLOW &W . Q 1 INDICATOR DRY VALVE Q,OD. MAKE MODEL I SERIAL NO. MAKE MODEL SERIAL NO. * TIME TO TRIP 71 tARM DRY PIPE THRU TEST WATER AIR TRIP REACHED OPERATED OPERATING CONNECTION PRESSURE PRE=SSUR RESSURE TEST OUTLET PROPERLY TEST MIN. A SEC. APSI PSI MIN, j SEC. YES I NO WTfHOUT Q.Q.D. WITH O.O.D. �r. - ', }�,,`• y IF NO, t i4 * MEASURED FROM TIME INSPECTORS TEST CONNECTION IS tJPENER, J, 85A �•,�' (OVER) gL� G i ? - OPERATION ❑ PNEUMATIC (:]ELECTRIC ❑HYDRAULIC -� y DELUGE PPEACTION YA YES PIPING SUPERVISED UYES LJNO NG MEDIA SUPERVISED UYES U NO DOES VALVE OPERATE FROM THE MANU DIOR REMOTE CONTROL STATIONS YES NO IS THERE AN ACCESSIBLE EACH CIRCUIT FOR TESTING ES ❑ NO IF NO, EXPLAIN DOES EACH CIRCUIT OPERATE DOES EACH CIRCUIT MAXIMUM TIME TO MODEL SUPERVISION LOSS ALARM OPERATE VALVE RELEASE OPERATE RELEASE TEST DESCRIPTION HYDROSTATIC: Hydrostatic tests shall be made at not less than 200 psi (13.6 bars) for two hours or 50 psi (3.4 bars) aWva static pressure in excess of 150p. (10.2 bars) for 14o hours. DIfferentlal dry-pipe valve clappers shell be loll open during lest to prevent damage. All above ground piping leakage shat( be stopper PNEUMATIC: Establish 40 psi (2.7 bars) air pressure and measure drop whlGh shall not exceed i -Y, psi (0.1 bars) In 24 hours. Test pressure lonks at normal watr ?1 level and air pressure and measure air pressure drop which shall not @xl 9oa 1 % psl (0.1 bars) In 24 hours. 1 ALL PIPI5G HYDROSTATICALLY TESTED AT PSI FOR cO, HR S. DRY PIPING PNEUMATICALLY TESTED UYES - ❑NO IF 0, VATE REASON EQUfPMENT OPERATES PROPERLY ❑YES ONO ty DO YOU CERTIFY AS THE.SPRINKL.ER SYSTEM CONTRACTOR THAT ADDITIVES AND CORROSIVE CHEMICALS, SODIUM SILICATE OR DERIVATIVES OF SODIUM SILICATE, BRINE, OR OTHER CORROSIVE CHEMICALS WERE NOT USED FOR TEST. TESTS ING SYSTEMS OR STOPPING LEAKS? OYES ❑NO DRAIN ST I G F GAGE LOCATED NEAR WAVR SUPPLY TEST CONNECTION; PSI RE IDUAI. PRESSURE WITH ALVE IN TEST CONNECTION OPEN WIDE to 3 PSI UNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE TO SPRINKLER PIPING, VERIFIED BY COPY OF THE U FORM NO. 85B OYES ❑ NO OTHER EXPLAIN FLUSHED BY INSTALLER OF UNDER• ROUND SPRINKLER PIPING ❑m ❑ NO BLANK TESTING NUMBER SED LOCATIONS NUMBER REMOVED CASKETS --7 WELDED PIPING UYES NO IF YES... DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY H THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL ARC ❑ YES ❑ NO DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED IN WELDING COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVELAP,3 ❑YES ONO DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A DOCUMENTED QUALITY CONTROL PROCEDURE TO INSURE THAT ALL DISCS ARE RETRIEVED, THAT OPENINGS IN PIPING ARE SMOOTH, THAT SLAG AND OTHER WELDING RESIDUE ARE REMOVED, AND THAT THE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED ❑YES ❑ NO CUTOUTS 00 YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL. DISCS CUTOUTS (DISCS) 'ARE RETRIED? 11 YES NO FUNCTIONAL FLOWTEST DOLES AHJ REQUIRE A FUNCTIONAL FLOW TEST OF RESIDENTIAL SPRINKLERS? U YES WERE FUNCTIONAL FLOW TEST RESULTS SATISFACTORY? OYES knNo NO NAME PLATE PROVIDED IF NO, EXPLAIN DATA NAMEPLATE al ES ONO F REMARKS DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: NAME OF SPRINKLER CONTRACTO ... �`` CONTRACTOR LICENSE a a �c� ! /a PATRIFP0990F TESTS WITNESSED BY SIGNATURES FOR PROPERTY OWNER (SIGNED) TITLE DATE- FOR SPRINKLE CO S T T E 6;P, DATE 1 l0'Ie- FO APPROVING A flR TITLE T 2 '- � -.a ✓ 7 r � s I CERTIFY THAT THE INFORMATION HEREIN 18 TRUE AND THAT THIS SPRINKLER SYSTEM WAS INSTALLED IN ACCORD - CE WITH RCW 18-160 AND THE RULES. ADOPTED BY THE WASHINGTON ADM[ ISTRATWE CODE AS ADMINISTERED BY CERTIFICATION HE STATE FIRE MARSHAL 1 ,u Tt+ .,� OF RTIFICATE MPEiENOY HOLDEN (PR!71T OR TYPE) el � &Y, - r-y 4r W OF FCA OFCOMPETENCYHOLDE ERTIFICATE REGISTRATION DATE Y a G ++CC D-Md Hmmr= ADDITIONAL E%PLANATK)N AND NOTES U 85.4 BACK . fix• - �Fp Oil PATRIOT FIRE PROTECTION CONTRACTORS MATERIAL & TEST REPORT FOR ABOVEGROUND PIPING PAOCEDUAE �.,�,.— �.. m ... ... ....... �,. w m...m .m .m......m Upon completion of work, Inspectlon and tests shall be made bythe contractor's representative and wltnessed by an owner's representative. All detects shall be corredled and system left In service before contractor's personnel finally leave the Job. Acertifloate shall be filled out and signed by both representatives. Copies shall be prepared for approving authorities, owners, and contractor, It Is under• stood the owner's representative's signature In noway prejudices any claim against contractor for faulty material, poor workmanship, or failure to comply with approving authority's requirements or local ordinances, a-19- 6s~ 1'hUrt-n I T AWLJ=cis Jed 0 9 )C 7A p . - % PLANS NS ACCEPTED BY APPROVING AUTHORITIES (NAME) ADDRESS INSTALLATION CONFORMS TO ACCEPTED PLANS EQUIPMENT USED IS APPROVED IF NO, EXPLAIN DEVIATIONS E NO B'fES ❑ NO INSTRUCTIONS HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION OF CONTROL VALVE AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT? IF NO, EXPLAIN ES LJNO HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES: 1. SYSTEM COMPONENTS INSTRUCTIONS Z CARE AND MAINTENANCE INSTRUCTIONS. S. NF.PA 13A NO ,,,�� [INC) I y'YES ONO D <S ❑NO• I LOCATION OF SYSTEM SYSTEM W a Sys lot SERVES: SPRINKLERS MAKE MODEL YEAR OF MANUFACTURE ORIFICE SITE QUANTITY TEMPERATURE RATING _5206 V— ° ' 'i— p 1,x IL !s` 08 r + PIPE AND FITTINGS TYPE OF PIPE e TYPE OF FITTINGS /-s ALARM VALVE OR FLOW INDICATOR � ALARM DEVICE MAXIMUM TIME TO OPERATE THROUGH TEST CONNECTION of TYPE. MAKE MODEL MIN SEC. pW ] DRY PIPE OPERATING TEST DRY VALVE MAKE I MODEL I SERIAL NO. MAKE MODEL SERIAL NO. * TIME TO TRIP RU TEST, iYN T N WATER PRESSURE AIR PRESSURE TRIP POINT Al TIME WATER GH TEST OUTLET ALARM OPERATED PROPERLY N. C. PSI PSI MIN. SEC. YES NO WITHOUTT O.O.D. WITH 1F N a 2 ' MEASURED FRUM INE INSPECTORS TEST GONNEUTION IS UPbgED _ , BSA.; (OVER) r� r YALV� S r, IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT f0FLTESTIN -IF NO;'EXPWN '" ' DOES EACH CIRCUIT OPERATE DOES EACH CIRCUIT MAXIMUM TIME TO MODEL SUPERVISION LOSS ALARM OPERATE VALVE RELEASE OPERATE RELEASE TEST DESCRIPTION HYDROSTATtlC; Hydroslatic tests shall be made al not less than 200 psl (13.8 bars) for two hours or 50 psi (3.4 bars) above static prossure In excess of S5o p (10.2 bars) for tvfo hours. Differential dry -pipe valve clappers shall be left open during test to prevent damage. All above ground piping leakage shall be atoppe, PNEUMATIC: Establlah 40 psi (2.7 bars) air pressure and measure drop which shall not exceed VA psi (0.1- bars)In 24 hours. Test pressure lanky at normal wah Tavel and a1r pressure and measure air pressure drop which shall not exceed 111,- psi (0.1 bars) In 24 hours. y -' f ALL PIPING D T TI Y TESTED AT P R F HR S. DRY PIPING PNEUMATICALLY TESTED YES .. . - -- E3 NO - - EQUIPMENT OPERATES PROPERLY ❑YES ONO IF N5. TAT R ON DO YOU CERTIFY AS THE.SPRINKLER SYSTEM CONTRACTOR THAT ADDITIVES AND CORROSIVE CHEMICALS, SODIUM SILICATE OR DERNATEVES OF SODIUM SILICATE, BRINE, OR OTHER CORPOSIVIE CHEMICALS WERE NOT USED FOR TEST- ING SYSTEMS OR STOPPING LEAKS? ❑YES 0 N TEST'S DRAIN READING 5F GAGE L TED NEAR WAT91ll RESIDUAL PRESSURE WITH VALVE INVEST ST SUPPLY TEST ONNECTiON: PSI CONNECTION OPEN WIDE PSI UNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE TO SPRINKLER PIPING. VERIFIED BY COPY OF THE U FORM NO. 85B ❑YES 0 NO OTHER EXPLAIN FLUSHED BY INSTALLER OF UNDER- GROUND SPRINKLER PIPING ❑YES ❑ NO BLANK TESTING NUMBER SED LOCATIONS NUMBER REMOVED CIASKETS WELOED PIPING LJYES NO IF YES. DO YOU CERTIFY AST E SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL ARC ❑ YES ❑ NO WELDING DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.0, LEVEL ARC ❑ YES ❑ NO DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A DOCUMENTED QUALITY CONTROL PROCEDURE TO INSURE THAT ALL DISCS ARE RETRIEVED, THAT OPENINGS IN PIPING ARE SMOOTH, THAT SLAG AND OTHER WELDING RESIDUE ARE REMOVED, AND THAT THE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED OYES ONO CUTOUTS_ DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL (DISCS) CUTOUTS (DISCS) ARE RETRIEVED? ❑YES NO FUNCTIONAL FLOWTEST DOES AI.1J REQUIRE A FUNCTIONAL FLOW TEST OF RESIDENTIAL SPRINKLERS? QYES MO WERE FUNCTIONAL FLOW TEST RESULTS SATISFACTORY? ' ❑YES MO DATA NAMEPLATE NAME PLATE PROVIDED YES 0 N IF NO, EXPLAIN REMARKS DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: — - U (2 NAME OF SPRINKLER CONTRACTOR CONTRACTOR LICENSE PATHIFP099CF TESTS WITNESSED BY SIGNATURES FOR PROPERTY OWNER (SIGNED) TITLE DATE - DATE- FOR SPRINKLE CO ( TT ` AT f� 0 ]] FOR APPROVING A TF ORITY PTLE DATE rA I CERTIFY THA THE INFORMATION HEREIN IS TRUE AND THAT THIS SPRINKLER SYSTEM WAS INSTALLED IN ACCORD- ANCE WITH RCW 18.160 AND THE RULES ADOPTED BY THE WA GTON ADMINI TRATIVE CODE AS ADMINISTERED BY CERTIFICATION HE STATE FIRE MARSHALd4 r r ` ^� j tiA! E PIPElENCY N,v..CER (PRINT OR TYPE) RE OF CEFITIFICATE OF ODMPETEHCY F10[DEf; CERTIFICATE REGISTRATION DATE"' 39147 5870 AUUITD14AL EYPLANA.WN AND NOTES 85A BACK +� - =D.10� 4"-St -Z� I LV I lU PATRIOT FIRE PROTECTION nn CONTRACTORS MATERIAL & TEST REPORT FOR ABOVEGROUND PIPING PROCEDURE,• -T�-:� �.,..w.. �.n.... .................................._...._......._. �....,.,..... �........., �... �...., �.,. �,,...,...........,...,..,.,.",..w........,............. m,. ,.,.�rt.,,.........,....,....... Upon completion of work, Inspection and tests shall be made bylhe contractor's representative and witnessed by an owner's representative. All defects shall be conedtad and system left In servioe before contractor's personnel finally leave the job. AceNfioate shall be filled out and signed by both representatives. Copies shall be prepared for approving authorities, owners, and contractor, his under- stood the owner's representative's signature in noway prejudices any claim against contractor for faulty material, poor workmanship, or (allure to comply with approving autharity'a requirements or local ordinances, - 1L-65- rnvrcnl T nuuneaa "Cr4 C q . )C )tA �� ✓ ' MEASURED FROM TIME SY� ' HS ILbT [:Urverrc;IIUry ib UrtNtL4 '"- ";M X�ps° BSA ` "7asi1 4X "` (OVER) ACCEPTED BY APPROVING AUTHORITIES (NAME) `7Pdrt�;+e VALG �rQnE ADDRESS t(n 3 I Cr SR+�f-1 u PAY 972 - 1/12'% PLANS INSTALLATION CONFORMS TO ACCEPTED PLANS NO EQUIPMENT USED IS APPROVED 01 S Q NO IF NO, EXPLAIN DEVIATIONS HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION UdYES U NO OF CONTROL VALVE AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT? IF NO, EXPLAIN HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES: YES NO INSTRUCTIONS 1. SYSTEM COMPONENTS INSTRUCTIONS 2 CARE AND MAINTENANCE INSTRUCTIONS. ES ONO ES ONO 3. NFPA 13A MYES ❑ NO , LOCATION OF SYSTEM SYSTI =M SERVES; UI Lei f • .L' "�'�% eA 3- YEAR OF ORJFICE TEMPERATURE MAKE MODEL MANUFACTURE SIZE QUANTITY RATING P�' -'1 SPRINKLERS , i a PIPE AND TYPE OF PIPE " ° G'• 1 .�st L� FITTINGS TYPE OF FITTINGS ALARM ' ALARM DEVICE MAXIMUM TIME TO OPERATE VALVE THROUGH TEST CONNECTION TYPE MAKE MODEL. MIN SE . OR FLOW i. r — INDICATOR DRY VALVE Q.OD. MAKE I MODEL I SERIAL NO. MAKE MODEL SERIAL NO. ' TIME TO TRIP TIME WATER ALARM DRY PIPE THRU TEST WATER AIR TRIP POINT REACHED OPERATED OPERATING CONNECTION PRESSURE PRESSURE AIR PRESSURE TEST OUTLET PR L-y-- TEST MIN. SEC. PSI ,,PSI, PSI MIN. YES I NO WITHOUT Q,O.D. A WITH V Q.O.D. ! s 1,il i IF NO, E7CPLAI U ' MEASURED FROM TIME SY� ' HS ILbT [:Urverrc;IIUry ib UrtNtL4 '"- ";M X�ps° BSA ` "7asi1 4X "` (OVER) VALVES I IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT FOR TESTING I IF NO, EXPLAIN 11 YES ❑NO DOES EACH CIRCUIT OPERATE D DOES EACH CIRCUIT M MAXIMUM TIME TO MAKE M MODEL S SUPERVISION LOSS ALARM O OPERATE VALVE RELEASE O OPERATE RELEASE YES N NO Y YES I I NO TEST H HYDROSTATIC: Hydrostatic tests shall be made at nc1 Esss than 200 psi (13.B bars) for two hours or W psi (3,4 bard above static pressure In excess of 15o p DESCRIPTION ( (10.2 bars) for two hours. Differential dry -pipe valve clappers shall be left open duitng test to prevent damage. Ali above ground piping leakage shell be stoppo PNEUMATIC: Estabtlsh 40 psi (2.7 be afr pressure and me asUre drop which shall not exceed 1•1/, psi (0.1 bars) In 24 hours. Test pressuro tanks at normal watr level and air pressure and measure air pressure drop which shall not exceed 11% psi (0.1 bars) In 24 hours. ALL PIPING HYMOSTPiCALLY TESTED AT PSI FOR HRS. I IF N, TATE AWON LW PIPING PNEUMATICALLY TESTED LZ+M9 ❑ NO 5 561s; T EQUIPMENT OPERATES PROPERLY ❑ YES .❑ NO T I't6t,25 D DO YOU CERTIFY AS THE SPRINKLER SYSTEM CONTRACTOR THAT ADDITIVES AND-CORROSIVE CHEMICALS, SODIUM SILICATE OR DERIVATIVES OF SODIUM SILICATE, BRINE, OR OTHER CORROSIVE CHEMICALS WERE NOT USED FOR TEST - 43 SYSTEMS OR STOPPING LEAKS? OYES ONO TESTS D DRAIN READING OF GAGE LOCATED NEAR WATER RES DUAL PRESSUAE WITH VALVE IN TEST ST SUPPLY TEST NNECTION: PSI CONNECTION OPEN WIDE 66 PSI UNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE TO SPRINKLER PIPING. RIFIED BY COPY OF THE U FORM NO. 85B OYES ❑ NO OTHER EXPLAIN FLUSHED BY INSTALLER OF UNDER - ROUND SPRINKLER PIPING ©YES ❑ NO BLANK TESTING N NUMBER USED L LOCATIONS NUMBER REMOVED GASKETS • • LDED PIPING UYES 0 IF YES... . DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY NIT H THE REQUIREMENTS OF AT LEAST AWS D10.% LEVEL AR-3 ❑ YES ❑ NO DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED IN WELnINQ D COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR-3 ❑ YES ❑ NO DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A DOCUMENTED QUALITY CONTROL, PROCEDURE TO INSURE THAT ALL DISCS ARE RETRIEVED, THAT OPENINGS IN PIPING ARE SMOOTH, THAT SLAG AND OTHER WEWING RESIDUE ARE REMOVED, AND THAT THE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED OYES ONO CUTOUTS D DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL DISCS C CUTOUTS DISCS ARE RETRIEVED? ❑}ES UNO FUNCTIONAL D DOES AHJ REQUIRE A FUNCTIONAL FLOW TEST OF RE81DENTIAL SPRINKLERS? NO FLOWTEST W WERE FUNCTIONAL FLOW TEST RESULTS SATISFACTORY? ❑YES NO HYDRAUUC N NAME PLATE PROVIDED I IF NO, EXPLAIN REMARKS D DATE WTI N SERVICE WITH ALL CONTROL VALVES OPEN; � � Z Sw G->Cv r N NAME OF SPRINKLER MT CTOR c o CONTRACTOR LICENSE # PATRIFP099CF TESTS WITNESSED BY SIGNATURES F FOR PROPERTY OWNER (SIGNED) TITLE DATE - FOR SPRINKLE R (SI ED TI D DATE jeo -0s I—WAL F FOR APP RUTH RI T TITt