The URL can be used to link to this page

31B-201 (5) 16. CERTIFICATIONS AND APPROVALS(continued) 16A Property or Owner Representative: This system,as specified herein,will be monitored according to all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: 16.5 Authority Having Jurisdiction: I have witnessed a satisfactory acceptance test of this system and find it to be installed and operating properly in accordance with its approved plans and specifications,with its approved sequence of operations,and with all NFPA standards cited herein. / Signed: Printed name:h„s�sf / �� Date: Organization: Title: � Phone: / Copyright 0 2009 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for oommercial sale or distribution. 15. RECORD OF SYSTEM OPERATIONAL ACCEPTANCE TEST ❑New system All operational features and functions of this system were tested by,or in the presence of the signer shown below,on the date shown below,and were found to be operating properly in accordance with the requirements for the following: ®Modifications to an existing system All newly modified operational features and functions of the system were tested by,or in the presence of the signer shown below,on the date shown below,and were found to be operating properly in accordance with the requirements of the following: ®NFPA 72,Edition: 2010 ❑NFPA 70,National Electrical Code,Article 760,Edition: 2011 ®Manufacturer's published instructions Other(specify): ❑Individual device testing documentation[Inspection and Testing Form(Figure 14.6.2.4)is attached] I Signe L- Printed name: John Hebert Date: 6/10/2014 Organizatio SimplexGrinnell Title: Tech Rep Phone: 413-733-3144 16. CERTIFICATIONS AND APPROVALS 16.1 System Installation Contractor: This system,as s cified here ,has been installed and tested according to all NFPA standards cited herein. Signed: Printed name: Dan Cordeiro Date: 6/11/2014 Organization: Universal Electric Title: Phone: 413-788-9473 16.2 System Service Contractor: The undersi ed has a service contract for this system in effect as of the date shown below. Signe �� Printed name: John Hebert Date: 6/10/2014 Or anizat' Si g mplexGrinnell Title: Tech Rep Phone: 413-733-3144 163 Supervising Station: This system,as specified herein,will be monitored according to all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: Copyright®2009 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. 13. SYSTEM POWER(continued) 13.3 Notification Appliance Power Extender Panels ®This system does not have power extender panels. 133.1 Primary Power Input voltage of power extender panel(s): N/A Power extender panel amps: Overcu rent protection: Type: Amps: Location(of primary supply panel board): Disconnecting means location: 133.2 Engine-Driven Generator ®This system does not have a generator. Location of generator: N/A Location of fizel storage: Type of fuel: 133.3 Uninterruptible Power System ®This system does not have a UPS. Equipment powered by a UPS system: N/A Location of UPS system: Calculated capacity of UPS batteries to drive the system components connected to it: In standby mode(hours): In alarm mode(minutes): 133.4 Batteries Location: N/A Type: Nominal voltage: Amp/hour rating: Calculated capacity of batteries to drive the system: In standby urs Y mode(hours): In alarm mode(minutes): ❑Batteries are marked with date of manufacture ❑Battery calculations are attached 14. RECORD OF SYSTEM INSTALLATION Fill out after all installation is complete and wiring has been checked for opens,shorts,ground faults,and improper branching,but before confucting operational acceptance tests. This is a: ❑New system ®Modification to an existing system Permit number: The system has been installed in accordance with the following requirements:(Note any or all that apply.) ®NFPA 72,Edition: 2010 ®NFPA 70,National Electrical Code,Article 760,Edition: 2011 ®Manufacturer's published instructions Other(specify): This Document covers (PHASE TWO) of MODIFIED Fire Alarm System System deviations from refe ced NFPA standards: Signed: ; Printed name: Dan Cordeiro Date: 6/11!2014 Organization: Universal Electric Title: Phone: 413-788-9473 Copyright 0 2009 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. 13. SYSTEM POWER(continued) 13.1.3 Uninterruptible Power System ❑This system does not have a LIPS. Equipment powered by a UPS system: N/A Location of UPS system: Calculated capacity of UPS batteries to drive the system components connected to it: In standby mode(hours): In alarm mode(minutes): 13.1.4 Batteries Location: FACU Type: LEADACID Nominal voltage: 24 Amp/hour rating: 50AH Calculated capacity of batteries to drive the system: In standby mode(hours): 24 In alarm mode(minutes): 10 ®Batteries are marked with date of manufacture ❑Battery calculations are attached 13.2 In-Building Fire Emergency Voice Alarm Communication System or Mass Notification System ®This system does not have an EVACS or MNS system. 13.2.1 Primary Power Input voltage of EVACS or MNS panel: N/A EVACS or MNS panel amps: Overcurrent protection: Type: Amps: Location(of primary supply panel board): Disconnecting means location: 13.2.2 Engine-Driven Generator ®This system does not have a generator. Location of generator: N/A Location of fuel storage: Type of fuel: 13.2.3 Uninterruptible Power System ®This system does not have a UPS. Equipment powered by a UPS system: N/A Location of UPS system: Calculated capacity of UPS batteries to drive the system components connected to it: In standby mode(hours): In alarm mode(minutes): 13.2.4 Batteries Location: N/A Type: Nominal voltage: Amp/hour rating: Calculated capacity of batteries to drive the system: In standby mode(hours): In alarm mode(minutes): ❑Batteries are marked with date of manufacture ❑Battery calculations are attached Copyright 0 2009 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. 11. TWO-WAY EMERGENCY COMMUNICATION SYSTEMS(continued) 113 Area of Refuge(Area of Rescue Assistance)Emergency Communications Systems ®This system does not have an area of refuge(area of rescue assistance)emergency communications system. Number of stations: N/A Location of central control point: Days and hours when central control point is attended: Location of alternate control point: Days and hours when alternate control point is attended: 11.4 Elevator Emergency Communications Systems ®This system does not have an elevator emergency communications system. Number of elevators with stations: N/A Location of central control point: Days and hours when central control point is attended: Location of alternate control point: Days and hours when alternate control point is attended: 11.5 Other Two-Way Communication Systems Describe: 12. CONTROL FUNCTIONS This system activates the following control factions: ❑Hold-open door releasing devices ❑Smoke management ®HVAC shutdown ®F/S dampers ❑Door unlocking ®Elevator recall ❑Fuel source shutdown ❑Extinguishing agent release ❑Elevator shunt trip ❑Mass notification system override of fire alarm notification appliances Other(specify): 12.1 Addressable Control Modules ❑This system does not have control modules. Number of devices: 19 Other(specify): Damper control,Elevator control,Trips for Campus Police 13. SYSTEM POWER 13.1 Control Unit 13.1.1 Primary Power Input voltage of control panel: 120 VAC Control panel amps: 20 Overcurrent protection: Type: CIRCUIT BREAKER Amps: 20 Location(of primary supply panel board): FACU Disconnecting means location: 13.1.2 Engine-Driven Generator ❑This system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: Copyright 0 2009 National Fire Protection Association.This form may be copied for Individual use other than for resale.It may not be copied for commercial sale or distribution. 10. MASS NOTIFICATION CONTROLS,APPLIANCES,AND CIRCUITS N Phis system does not have an MNS. 10.1 MNS Local Operating Consoles Location 1: N/A Location 2: Location 3: 10.2 High-Power Speaker Arrays Number of UPSA speaker initiation zones: Location l: N/A Location 2: Location 3: 10.3 Mass Notification Devices Combination fire alann/MNS visible appliances: N/A MNS-only visible appliances: Textual signs: N/A Other(describe): Supervision class. N/A 103.1 Special Hazard Notification N This system does not have special suppression predischarge notification. ❑MNS systems DO NOT override notification appliances required to provide special suppression predischarge notification. 11. TWO-WAY EMERGENCY COMMUNICATION SYSTEMS 11.1 Telephone System N This system does not have a two-way telephone system. Number of telephone jacks installed: N/A Number of warden stations installed: Number of telephone handsets stored on site: Type of telephone system installed: ❑Electrically powered ❑Sound powered 11.2 Two-Way Radio Communications Enhancement System N This system does not have a two-way radio communications enhancement system. Percentage of area covered by two-way radio service: Critical areas: % General building areas: % Amplification component locations: N/A Inbound signal strength: dBm Outbound signal strength: dBm Donor antenna isolation is: dB above the signal booster gain Radio frequencies covered: Radio system monitor panel location: Copyright 0 2009 National Fire Protection Association.This form my be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. 7. MONITORED SYSTEMS 7.1 Engine-Driven Generator ❑This system does not have a generator. 7.1.1 Generator Functions Supervised ❑Engine or control panel trouble ❑Generator running ❑Selector switch not in auto ❑Low fuel ❑Other(specify): 7.2 Special Hazard Suppression Systems ❑This system does not monitor special hazard systems. Description of special hazard system(s): 7.3 Other Monitoring Systems ❑This system does not monitor other systems. Description of special hazard system(s): 8. ANNUNCIATORS ❑This system does not have annunciators. 8.1 Location and Description of Annunciators Location 1: LCD Cutter lobby Entrance Location 2: Location 3: 9. ALARM NOTIFICATION APPLIANCES 9.1 In-Building Fire Emergency Voice Alarm Communication System ®This system does not have an EVACS. Number of single voice alarm channels: N/A Number of multiple voice alarm channels: Number of speakers: N/A Number of speaker circuits: Location of amplification and sound-processing equipment: Location of paging microphone stations: Location 1: N/A Location 2: Location 3: 9.2 Nonvoice Notification Appliances ❑This system does not have nonvoice notification appliances. Horns: 123 With visible: 112 Bells: With visible: Chimes: N/A With visible: Visible only: 6 Other(describe): SOUNDER BASE W/SMOKE DETECTORS 93 Notification Appliance Power Extender Panels ®This system does not have power extender panels. Quantity: N/A Locations: AW* Copyright 0 2009 National Fire Protection Association.This forth may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. 5. ALARM INITIATING DEVICES (continued) 5.2.6 Addressable Monitoring Modules ❑This system does not have monitoring modules. Number of devices: 12 5.2.7 Waterflow Alarm Devices ❑This system does not have waterflow alarm devices. Type and number of devices: Addressable: 2 Conventional: N/A Coded: Transmitter: 5.2.8 Alarm Verification ❑This system does not incorporate alarm verification. Number of devices subject to alarm verification: 141 Alarm verification set for: 45 seconds 5.2.9 Presignal ❑This system does not incorporate pre-signal. Number of devices subject to presignal: N/A Describe presignal functions: 5.2.10 Positive Alarm Sequence(PAS) ❑This system does not incorporate PAS. Describe PAS: N/A 5.2.11 Other Initiating Devices ❑This system does not have other initiating devices. Describe: N/A 6. SUPERVISORY SIGNAL-INITIATING DEVICES 6.1 Sprinkler System Supervisory Devices ❑-this system does not have sprinkler supervisory devices. Type and number of devices: Addressable: 3 Conventional: N/A Coded: N/A Transmitter: Other(specify): 6.2 Fire Pump Description and Supervisory Devices ❑This system does not have a fire pump. Type fire pump: ❑Electric pump ❑Engine Type and number of devices: Addressable: Conventional: Coded: Transmitter: Other(specify): 6.2.1 Fire Pump Functions Supervised ❑Power ❑Running ❑Phase reversal ❑Selector switch not in auto ❑Engine or control panel trouble ❑Low fuel Other(specify): 63 Duct Smoke Detectors(DSDs) ❑This system does not have DSDs causing supervisory signals. Type and number of devices: Addressable: Conventional: 4 Other(specify): Conventional Duct Detector with addressable modules Type of coverage: Type of smoke detector sensing technology: ❑Ionization ®Photoelectric ❑Aspirating ❑Beam 6.4 Other Supervisory Devices El'Ibis system does not have other supervisory devices. Describe: Copyright®2009 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. Amok 5. ALARM INITIATING DEVICES 5.1 Manual Initiating Devices 5.1.1 Manual Fire Alarm Boxes ❑This system does not have manual fire alarm boxes. Type and number of devices: Addressable: 20 Conventional: N/A Coded: N/A Transmitter: N/A Other(specify): 5.1.2 Other Alarm Boxes ❑This system does not have other alarm boxes. Description: N/A Type and number of devices: Addressable: Conventional: Coded: Transmitter: Other(specify): 5.2 Automatic Initiating Devices 5.2.1 Smoke Detectors ❑This system does not have smoke detectors. Type and number of devices: Addressable: 261 Conventional: N/A Other(specify): N/A Type of coverage: ❑Complete area ❑Partial area ❑Nonrequired partial area Other(specify): N/A Type of smoke detector sensing technology: ❑Ionization E Photoelectric ❑Multicriteria ❑Aspirating ❑Beam Other(specify): 5.2.2 Duct Smoke Detectors ❑This system does not have alarm-causing duct smoke detectors. Type and number of devices: Addressable: Conventional: Other(specify): N/A Type of coverage: NIA Type of smoke detector sensing technology: ❑Ionization E Photoelectric ❑Aspirating ❑Beam 5.23 Radiant Energy(Flame)Detectors ❑This system does not have radiant energy detectors. Type and number of devices: Addressable: Conventional: Other(specify): Type of coverage: 5.2.4 Gas Detectors ❑This system does not have gas detectors. Type of detector(s): Carbon Monoxide Detectors Number of devices: Addressable: Conventional: 7 Type of coverage: Conventional C/O Detector with addressable modules 5.2.5 Heat Detectors ❑This system does not have heat detectors. Type and number of devices: Addressable: 3 Conventional: Type of coverage: ❑Complete area ❑Partial area ❑Nonrequired partial area ❑Linear E Spot Type of heat detector sensing technology: E Fixed temperature ®Rate-of-rise ❑Rate compensated Copyright 0 2009 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. 4. CIRCUITS AND PATHWAYS 4.1 Signaling Line Pathways 4.1.1 Pathways Class Designations and Survivability Pathways class: A Survivability level: 2 Quantity: 2 (See NFPA 72,Sections 12.3 and 12.4) 4.1.2 Pathways Utilizing Two or More Media Quantity: Description: 4.1.3 Device Power Pathways ❑No separate power pathways from the signaling line pathway ❑Power pathways are separate but of the same pathway classification as the signaling line pathway ❑Power pathways are separate and different classification from the signaling line pathway 4.1.4 Isolation Modules Quantity: 4 Isolated paths on Idnet Chanel 1 4.2 Alarm Initiating Device Pathways 4.2.1 Pathways Class Designations and Survivability Pathways class: A Survivability level: 2 Quantity: 6 (See NFPA 72,Sections 12.3 and 12.4) 4.2.2 Pathways Utilizing Two or More Media Quantity: Description: 4.2.3 Device Power Pathways ❑No separate power pathways from the initiating device pathway ❑Power pathways are separate but of the same pathway classification as the initiating device pathway ❑Power pathways are separate and different classification from the initiating device pathway 4.3 Non-Voice Audible System Pathways 4.3.1 Pathways Class Designations and Survivability Pathways class: B Survivability level: 1 Quantity: 39 (See NFPA 72,Sections 12.3 and 12.4) 4.3.2 Pathways Utilizing Two or More Media Quantity: N/A Description: 4.3.3 Device Power Pathways ®No separate power pathways froth the notification appliance pathway ❑Power pathways are separate but of the same pathway classification as the notification appliance pathway ❑Power pathways are separate and different classification from the notification appliance pathway Copyright 0 2009 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial safe or distribution. 3. DESCRIPTION OF SYSTEM OR SERVICE(continued NFPA 72 edition: 2010 Additional description of system(s): N/A 3.1 Control Unit Manufacturer: SimplexGrinnell Model number: 4100ES 3.2 Mass Notification System ®This system does not incorporate an MNS 3.2.1 System Type: ❑In-building MNS---combination ❑In-building MNS--stand-atone ❑Wide-area MNS ❑Distributed recipient MNS ❑Other(specify): N/A 3.2.2 System Features: ❑Combination fire alarm/MNS ❑MNS autonomous control unit ❑Wide-area MNS to regional national alerting interface ❑Local operating console(LOC) ❑Direct recipient MNS(DRMNS) ❑Wide-area MNS to DRMNS interface ❑Wide-area MNS to high-power speaker array(IFSA)interface ❑In-building MNS to wide-area MNS interface ❑Other(specify): N/A 3.3 System Documentation ®An owner's manual,a copy of the manufacturer's instructions,a written sequence of operation,and a copy of the numbered record drawings are stored on site. Location: Physical Plant 3.4 System Software Y 11 This system does not have alterable site-specific software. Operating system(executive)software revision level: 2.01.01 Site-specific software revision date: 8/10/2014 Revision completed by: John Hebert ®A copy of the site-specific software is stored on site. Location: at FACU 3.5 Off-Premises Signal Transmission ❑This system does not have off-premises transmission. Name of organization receiving alarm signals with phone numbers: Alarm: Mt.Holyoke College Dispatch Phone: 413-585-2490 Supervisory: Mt.Holyoke College Dispatch Phone: 413-585-2490 Trouble: Mt.Holyoke College Dispatch Phone: 413-585-2490 Entity to which alarms are retransmitted: Northampton Fire Dept Phone: 413-587-1032 Method of retransmission: Landline If Chapter 26,specify the means of transmission from the protected premises to the supervising station: Digital/Fiber optics If Chapter 27,specify the type of auxiliary alarm system: ❑Local energy ❑Shunt ❑Wired ❑Wireless Copyright 0 2009 National Fire Protection Association.This form may be copied for individual use other than for resale-It may not be copied for commercial sale or distribution. eok FIRE ALARM AND EMERGENCY COMMUNICATION SYSTEM RECORD OF COMPLETION To be completed by the system installation contractor at the time ofsystem acceptance and approval. It shall be permitted to modify this form as needed to provide a more complete and/or clear record. Insert N/A in all unused lines. Attach additional sheets,data,or calculations as necessary to provide a complete record. 1. PROPERTY INFORMATION Name of P roe P rty Cutter/Ziskind House Phase 2 Address: Elm Street,Northampton, MA Description of property: Dorm Occupancy type: R2 Name of property representative: Smith College Address: Phone: Fax: E-mail: Authority having jurisdiction over this property: Northampton Fire Dept. Phone: 413-587-1032 Fax: E-mail: 2. INSTALLATION,SERVICE,AND TESTING CONTRACTOR INFORMATION Installation contractor for this equipment: Univeral Electric Co.lnc Address: 59 Observer St,Springfield,MA 01104 License or certification number: Massachusetts License# Phone: (413)788-9473 Fax: E-mail: Service organization for this equipment: SimplexGrinnell Address: 66 Myron Street,West Springfield,MA 01089 License or certification number: 17359A Phone: 413-733-3144 Fax: 413-734-7650 E-mail. Dsimkewicz @simplexgrinnell.com A contract for test and inspection in accordance with NFPA standards is in effect as of N/A Contracted testing company: SimplexGrinnell Address: N/A Phone: N/A Fax: N/A E-mail: N/A Contract expires: N/A Contract number: N/A Frequency of routine inspections: NIA 3. DESCRIPTION OF SYSTEM OR SERVICE ®Fire alarm system(nonvoice) ❑Fire alarm with in-building fire emergency voice alarm communication system(EVACS) ❑Mass notification system(MNS) ❑Combination system,with the following components: ❑Fire alarm ❑EVACS ❑MNS ❑Two-way,in-building,emergency communication system ❑Other(specify): N/A opk Copyright®2009 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. OPERATION PNEUMATIC ELECTRIC I HYDRAULIC DELUGE& PRE- PIPING SUPERVISED YES NO I DETECTING MEDIA SUPERVISED I YES. NO ACTION VALVES DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATION YES NO IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT FOR TESTING IF NO,EXPLAIN EDYESF7NO DOES EACH CIRCUIT DOES EACH CIRCUIT MAXIMUM TIME TO OPERATE SUPERVISION MAKE MODEL OPERATE VALVE RELEASE OPERATE RELEASE LOSS ALARM S I NO YES N YES N HYDROSTATIC: Hydrostatic tests shall be made at not less than 200 psi(13.6 bars)for two tours or 50 psi(3.4 bars)above static pressure in excess of 150 psi(10.2 bars)for two hours. Differential dry-pipe valve clappers shall be left open during test to prevent TEST damage. All aboveground piping leakage shall be stopped. DESCRIPTION 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(1514 Umin)for 4-inch pipe,800 GPM(2271 Umin)for 5-Inch pipe,'60 GPM(2839 Umin)for 12-inch pipe.When apply cannot produce stipulated flow rates,obtain maximum available. PNEUMATIC: Establish 40 psi(2.7 bars)air pressure and measure drop which shall not exceed 1-1/2 psi(0.1 bars)in 24 tours. Test assure tanks at normal water level and air pressure and measure air pressure droo which shall not exceed 1-1 i 0.1 bars in 24 tours. ALL PIPING HYDROSTATICALLY TESTED AT 2A, PSI FOR HRS. IF NO,STATE REASON DRY PIPING PNEUMATICALLY TESTED YES NO EQUIPMENT OPERATES PROPERLY YES NO READING OF GAGE LOCATED NEAR WATER SUPPLY TEST PIPE_ RESIDUAL PRESSURE WITH VALVE I EST TESTS DRAIN TEST STATIC PRESSURE: PSI PIPE 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.858 =YES ®NO JOTHER EXPLAIN FLUSHED BY INSTALLER OF UNDER GROUND SC/51'/!✓4 G(JAt�7Z S�2V/� SPRINKLER PIPING YES NO TANK TESTING NUMBER USED LOCATIONS NUMBER REMOVED AND GASKETS Z511 WELDING PIPING VIYESI I NO IF YES........ DO YOU CERTIFY AS THE SPRINKLER CONTRA OR THAT WELDING PROCEDURES rC� COMPLY WITH THE REQUIREMENTS OF AT LEAST AWS D10.9,LEVEL AR-3 IJ YES=NO DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED WELDING 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 NO HYDRAULIC DATA NAMEPLATE PROVIDED IF NO,EXPLAIN NAMEPLATE 591 YES No DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: REMARKS NAME OF SPRINKLER CONTRACTOR _ TESTS WITNESSED BY SIGNATURES FOM!9PERIY OWNER SI� TITLE DAT 4o- F05,SP�VKtTRCONT CTO SI TITLE DATEI ADDITIONAL EXPLANATION AND NOTES CONTRACTOR'S MATERIAL TEST CERTIFICATE FOR ABOVEGROUND PIPING PROCEDURE Upon completion of work,inspection and tests shall be made by the contractor's representative and witnessed by an owner's representative. All defects shall be corrected and system left in service before contractor's personnel finally leave the lob. 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 property owner's authorized representative is a legal signatory and fully representative of the property owner and that by the property owner's:or property owner's suthonzed representative's signature,the property owner accepts full responsibility for the system as installed and agrees that it is in lianoe with the applicable a authority's requirements end local ordinances. PR P R E DATE Z / .S / Tl�. COG[6G L 17X-a O OW -2 PROPER �G/ '�T drG,zl1 row 104 ACCEPTED BY APPROVING AUTHORITY C )NAMES 4o c l/T ADDRESS . PLANS INSTALMION CONFORMS TO ACCEPTED PI A S YES NO: EQUIPMENT USED IS APPROVED ES N YES NO BEEN INSTRUCTED AS TO LOCATION OF CONTROL VALVES AND CARE AND MAINTENANC IS NE IPM ENT PLAIN INSTRUCTIONS HAVE COPIES OF THE FOLLOWING BEEN GIVEN TO THE PROPERTY OWNER OR PROPERTY OWNER'S AUTHORIZED REPRESENTATIVE: t.SYSTEM COMPONENTS INSTRUCTIONS 7eYES _NO 2.CARE AND MAINTENANCE INSTRUCTIONS: YES _NO 3. NFPA 25: YES NO LOCATION OF SUPPLIES BLDGS. SYSTEM &AS MAKE MODEL YEAR OF ORIFICE SIZE QUANTITY T PERATURE RATIN G in MANUFACTURE degrees U-48e '�DtM Zv1 /S A V laNf Zo1 2I2 SPRI S NKLER PIPE CONFORMS TO STANDARD YESI I NO PIPE AND FITTINGS CONFORM TO A16M -/ STANDARD YES NO ri FITTINGS IF NO,EXPLAIN ALARM DEVISE MAXIMUM TIME TO OPERATE THROUGH TEST PIPE ALARM VALVE OR TYPE MAKE MODEL MIN. SEC. FLOW INDICATOR r N `iM n2 DRY VALVE Q.O.D. MAKE MODEL SERIAL NO. MAKE MODEL SERIAL N0. DRY PIPE TIME WATER ALARM OPERATED TIME TO TRIP WATER AIR PRESSURE TRIP POINT AIR REACHED TEST OPERATING TEST THRU TEST PIPE PRESSURE PRESSURE OUTLET PROPERLY MIN. SEC. PSI. PSI. PSI. MIN. SEC. YES NO Without Q.O.D. With 0.0.0 IF NO,EXPLAIN OPERATION PNEUMATIC ELECTRIC HYDRAULIC DELUGE S PRE- PIPING SUPERVISED YES I NO I DETECTING MEDIA SUPERVISED I YES INO ACTION VALVES DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATION YES NO IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT FOR TESTING IF NO,EXPLAIN YES f NO DOES EACH CIRCUIT DOES EACH CIRCUIT MAXIMUM TIME TO OPERATE SUPERVISION MAKE MODEL LOSS ALARM OPERATE VALVE RELEASE OPERATE RELEASE YES I NO YES I NO YES N HYDROSTATIC: Hydrostatic tests shall be made at not less than 200 psi(13.6 bars)for two hours or 50 psi(3.4 bars)above static pressure in excess of 150 psi(101 bars)for two hours. Differential dry-pipe valve clappers shall be left open during test to prevent TEST damage. All aboveground piping leakage shall be stopped. FLUSHING: Flow the required rate until water is clear as indicated by no collection of foreign materiel in burlap bags at outlets such as DESCRIPTION hydrants and blow-offs. Flush at flows not less than 400 GPM(1514 Umin)for flinch pipe,600 GPM(2271 Umin)for 5-inch pipe,750 GPM(2839 Umin)for 12-inch pipe.When supply cannot produce stipulated flow rates,obtain maximum available. PNEUMATIC: Establish 40 psi(2.7 bars)air pressure and measure drop which shall not exceed 1-1/2 psi(0.1 bars)in 24 hays. Test Pressure tanks at normal water level and air Pressure and measure air pressure drOD which shall not exceed 1-1/ psi 0.1 bars in 24 hours, ALL PIPING HYDROSTATICALLY TESTED AT 21& PSI FOR HRS. IF NO,STATE REASON DRY PIPING PNEUMATICALLY TESTED YES NO EQUIPMENT OPERATES PROPERLY YES NO READING OF GAGE LOCATED NEAR WATER SUPPLY TEST PIPE. RESIDUAL PRESSURE WITH VAL TEST TESTS DRAIN TEST STATIC PRESSURE: PSI PIPE 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 ©NO O EXPLAIN FLUSHED BY INSTALLER OF UNDER GROUND /ST/Ne,. �(f� L S�Q(JIC.C� SPRINKLER PIPING YES I TANK TESTING NUMBER USED LOCATIONS NUMBER REMOVED AND GASKETS WELDING PIPING YE5 NO f° IF YES........ DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY WITH THE REQUIREMENTS OF AT LEAST AWS D10.9,LEVEL AR-3 177-n YES=NO DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED WELDING IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.9,LEVEL AR-3 r;C]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 MNO HYDRAULIC DATA NAMEPLATE PROVIDED IF NO,EXPLAIN NAMEPLATE [z]YES C] No DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN'. REMARKS NAME OF SPRINKLER CONTRACTOR �9/LEf/©�•a5� 1Y�C'G�1�9N�4tc G.�owtn�r��' .��✓c., TESTS WITNESSED SY SIGNATURES FOR PROPVTY (SIG ED) TITLE DA FOR RIN E CT R(SINGED TITLE D E - I _ADDITIONAL EXPLANATION AND NOTES CONTRACTOR'S MATERIAL TEST CERTIFICATE FOR ABOVEGROUND PIPING PROCEDURE Upon completion of work,inspection and tests shall be made by the contractor's representative and witnessed by an owners representative. All defects shall be corrected and system left in service before contractor's personnel finally leave the job. A certificate shall be filled out and signed by both representatives. Copies shall be prepared for approving authorities,owners and contractor. It is understood the property owners authorized representative is a legal signatory and fully representative of the property owner and that by the property owners or property owner's authorized representative's signature,the property owner accepts full responsibility for the system as installed and agrees that it is in compliance with the applicable approving authority's requirements and local ordinances. PROPERTY NAME DATE PROPERTY ADDRESS ACCEPTED BY APPROVING AUTHORITY('S)NAMES ka 64 c /-1 T ADDRESS PLANS INSTALLATION CONFORMS TO ACCEPTED PLANS YES NO EQUIPMENT USED IS APPROVED YES NO AUTHORIZED HAS PROPERTY OWNER OR PROPERTY OWNER'S YES NO BEEN INSTRUCTED AS TO LOCATION OF CONTROL VALVES AND CARE AND MAINTENANC S NE IPMENT PLAIN INSTRUCTIONS OWNER PROPERTY OWNER'S AUTHORIZED REPRESENTATIVE: 1.SYSTEM COMPONENTS INSTRUCTIONS 7eYES NO 2.CARE AND MAINTENANCE INSTRUCTIONS: YES_NO 3. NFPA 25: YES NO LOCATION OF SUPPLIES BLDGS. SYSTEM 56W6 MAKE MODEL YEAR ORIFICE SIZE QUANTITY TEMPERATURE RATING in MANUFACTURE degrees s�/3 .: vF12/lr,Ia 1 zo I 2/2 SPRINKLERS PIPE CONFORMS TO STANDARD YES NO PIPE AND FITTINGS CONFORM TO ^/ -/_3 STANDARD YES NO FITTINGS IF N0,EXPLAIN ALARM DEVISE MAXIMUM TIME TO OPERATE THROUGH TEST PIPE ALARM VALVE OR TYPE I MAKE MODEL MIN. SEC. FLOW INDICATOR rlow i eN p 'rM v2 DRY VALVE Q.O.D. MAKE MODEL SERIAL NO. MAKE MODEL I SERIAL NO. DRY PIPE TIME WATER TIME TO TRIP WATER AIR PRESSURE TRIP POINT AIR REACHED TEST ALARM OPERATED OPERATING TEST THRU TEST PIPE PRESSURE PRESSURE OUTLET PROPERLY MIN. SEC. PSI. PSI. PSI. MIN. SEC. YES NO Without O.O.D. With Q.O. IF NO,EXPLAIN OPERATION PNEUMATIC ELECTRIC I HYDRAULIC DELUGE&PRE- PIPING SUPERVISED YES NO I DETECTING MEDIA SUPERVISED YES NO ACTION VALVES DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATION YES NO IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT FOR TESTING IF NO,EXPLAIN YES NO DOES EACH CIRCUIT DOES EACH CIRCUIT MAXIMUM TIME TO OPERATE SUPERVISION MAKE MODEL LOSS ALARM OPERATE VALVE RELEASE OPERATE RELEASE YES I NO YES No YES I NO HYDROSTATIC: Hydrostatic tests shall be made at riot less than 200 psi(13.6 bars)for two hours or 50 psi(3.4 bars)above static pressure in excess of 150 psi(10.2 bars)for two hours. Differential dry-pipe valve clappers shall be left open during test to prevent TEST damage All aboveground piping leakage shall be stopped FLUSHING: Flow the required rate until water is dear as indicated by no collection of foreign material in burlap bags at outlets such as DESCRIPTION hydrants and blow-offs. Flush at flows not less than 400 GPM(1514 Umin)for 4-inch pipe,600 GPM(2271 Umin)for 5-Inch pipe,750 GPM(2839 L/min)for 12-inch pipe.When supply cannot produce stipulated flow rates,obtain maximum available. PNEUMATIC: Establish 40 psi(2.7 bars)air pressure and measure drop which shall not exceed 1-112 psi(0.1 bars)in 24 hours. Test assure nk at or al water level it Prilis3ure and measure air oressure droD which shall not exceed 1-1 s' 0 4 hours. ALL PIPING HYDROSTATICALLY TESTED AT 2.60PS1 FOR HRS. IF NO,STATE REASON DRY PIPING PNEUMATICALLY TESTED YES NO E UIPMENT OPERATES PROPERLY YES NO READING OF GAGE LOCATED NEAR WATER SUPPLY TEST PIPE. RESIDUAL PRESSURE WITH VALVeINTEST TESTS DRAIN TEST STATIC PRESSURE: PSI PIPE OPEN WIDE PSI Underground mains and lead in connections to system risers bushed before connection made to sprinkler piping. VERIFIED BY COPY OF THE U FORM NO.858 =YES rWNO OTHER EXPLAIN FLUSHED BY INSTALLER OF UNDER GROUND 16Y4577019 RNs!TC'7L ��IL��GI✓ SPRINKLER PIPING YES NO TANK TESTING NUMBER USED LOCATIONS NUMBER REMOVED AND GASKETS WELDING PIPING YES NO IF YES........ DO YOU CERTIFY AS THE SPRINKLER CONTR A TOR THAT WELDING PROCEDURES rn COMPLY WITH THE REQUIREMENTS OF AT LEAST AWS D10.9,LEVEL AR-3 T YES=NO DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED WELDING IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D1 CIA LEVEL AR-3 [�YES[=N0 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 HYDRAULIC DATA NAMEPLATE PROVIDED T77XPLAIN NAMEPLATE ®YES= NO DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: REMARKS NAME OF SPRINKLER CONTRACTOR TESTS WITNESSED BY FOXPOPrTY OWNER(SIGNED) TITLE DATE SIGNATURES Ul(/ F PR NKLE .0 TRACTOR(SIN TITLE DATE ADDITIONAL EXPLANATION AND NOTES CONTRACTOR'S MATERIAL TEST CERTIFICATE FOR ABOVEGROUND PIPING PROCEDURE Upon completion of work,inspection and tests shall be made by the contractor's representative and witnessed by an owner's representative. All defects shall be corrected and system left in service before contractor's personnel finally leave the job. A certificate shall be filled out and signed by both representatives. Copies shall be prepared for approving authorities,owners and contractor, it is understood the property owners authorized representative is a legal signatory and fully representative of the property owner and that by the property owners or property owner's authorized representative's signature,the property owner accepts full responsibility for the system as installed and agrees that it is in compliance with the applicable approving authority's requirements and local ordinances. PROPERTY NAME DATE PROPERTY ADDRESS, F(-m 5T4cer ACCEPTED BY APP OVING AUTHORITY('S)NAMES Zoufc, 414-T ADDRESS PLANS INSTALLATION CONFORMS TO ACCEPTED PLANS YES NO EQUIPMENT USED IS APPROVED Y NO HAS PROPERTY OWNER OR PROPERTY OWNER'S AUTHORIZED REPRESENTATIVE YES NO BEEN INSTRUCTED AS TO LOCATION OF CONTROL VALVES AND CARE AND MAINTENANC IS NEW-EQUIPMENT INSTRUCTIONS HAVE I PROPERTY OWNER'S AUTHORIZED REPRESENTATIVE: 1.SYSTEM COMPONENTS INSTRUCTIONS '/YES NO 2.CARE AND MAINTENANCE INSTRUCTIONS: YES NO 3. NFPA 25: YES NO LOCATION OF SUPPLIES BLDGS. SYSTEM 1-2c)u" �L4Dr� MAKE MODEL YEAR OF ORIFICE SIZE QUANTITY TEMPERATURE TING in MANUFACTURE degrees SPRINKLERS ' 't_ 2 /S PIPE CONFORMS TO 4y ,+If /3 STANDARD YESI I NO PIPE AND FITTINGS CONFORM TO /{/Fps ? STANDARD YES NO FITTINGS IF NO,EXPLAIN ALARM DEVISE MAXIMUM TIME TO OPERATE THROUGH TEST PIPE ALARM VALVE OR TYPE MAKE MODEL MIN. SEC. FLOW INDICATOR flora S'wl&M AtCA I W,K „laSo12 DRY VALVE Q.O.D. t"KE MODEL SERIAL NO. MAKE MODEL SERIAL NO. /V DRY PIPE TIME TO TRIP WATER TRIP POINT AIR TIME W R ALARM OPERATED OPERATING TEST THRU TEST PIPE PRESSURE AIR PRESSURE PRESSURE REACHED TEST PROPERLY OUTLET MIN, SEC. PSI. PSI. PSt. MIN. SEC. YES NO Without Q.O.D. With 0.0, IF N0 XPLAIN E OPERATION PNEUMATIC I ELECTRIC I HYDRAULIC DELUGE&PRE- PIPING SUPERVISED YES NO I DETECTING MEDIA SUPERVISED YES I NO ACTION VALVES DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATION YES I NO IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT FOR TESTING IF NO,EXPLAIN F7YES NO DOES EACH CIRCUIT DOES EACH CIRCUIT MAXIMUM TIME TO OPERATE SUPERVISION MAKE MODEL LOSS ALARM OPERATE VALVE RELEASE OPERATE RELEASE YES I N YES N HYDROSTATIC: Hydrostatic tests shall be made at not less than 200 psi(13.6 bars)for two hours or 50 psi(3A bars)above static pressure in excess of 150 psi(10.2 bars)for two hours. Differential dry-pipe valve clappers shall be left open during test to prevent TEST damage. All aboveground piping leakage shalt be stopped. FLUSHING: Flow the required rate until water is clear as indicated by no collection of foreign material in burlap begs at outlets such as DESCRIPTION hydrants and blow-offs. Flush at flows not less than 400 GPM(1514 Umin)for 4-inch pipe,600 GPM(2271 Umtn)for 54nch pipe,750 GPM(2839 Umin)for 124nch pipe.When supply cannot produce stipulated flow rates,obtain maximum available. PNEUMATIC: Establish 40 psi(2.7 bars)air pressure and measure drop which shall not exceed 1-1/2 psi(01 bars)in 24 hours. Test re tanks at normal water level and air pressure and measure air Dressure droo which shall not ex 1-112 psi 0. 4 ALL PIPING HYDROSTATICALLY TESTED AT bbPSI FOR MRS. IF NO,STATE REASON DRY PIPING PNEUMATICALLY TESTED YES NO EQUIPMENT OPERATES PROPERLY YES NO READING OF GAGE LOCATED NEAR WATER SUPPLY TEST PIPE. RESIDUAL PRESSURE WITH VALVE TEST TESTS DRAIN TEST STATIC PRESSURE. PSI PIPE 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 rWNO OTHER EXPLAIN FLUSHED BY INSTA SPRINKLER PIPING LLER OF UNDER GROUND YES NO Lc7USnN b A4JkM TANK TESTING NUMBER USED LOCATIONS NUMBER REMOVED AND GASKETS WELDING PIPING YES NO IF YES........ DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY WITH THE REQUIREMENTS OF AT LEAST AWS 010.9,LEVEL AR-3 YES=NO DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED WELDING 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 [:BYES NO HYDRAULIC DATA NAMEPLATE PROVIDED IF NO,EXPLAIN NAMEPLATE ®YES= NO DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: REMARKS NAME OF SPRINKLER CONTRACTOR 2c'NovS� e CA4A.)1C4L L�,4ervAls -mac TESTS WITNESSED BY SIGNATURES FOR PROPER OWNER(SIGNE TITLE DATE � 1-1 FOR RINKLER C TRAM R(SINGED TITLE DATE ADDITIONAL EXPLANATION AND NOTES CONTRACTOR'S MATERIAL TEST CERTIFICATE FOR ABOVEGROUND PIPING PROCEDURE Upon completion of work,inspection and tests shall be made by the contractor's representative and witnessed by an owner's representative. All defects shell be corrected and system left in service before contractor's personnel finally leave the lob. A certificate shalt be filled out and signed by both representatives. Copies shall be prepared for approving authorities,owners and contractor. It Is understood the property owner's authorized representative is a legal signatory and fully representative of the Property owner and that by the property owner's or property owner's authorized representative's signature,the property owner accepts full responsibility for the system as installed and agrees tlut it Is In ER NAME i with the aPPlioeble a i authori s requirements and local ordinances. P DATE S Mr# C464e-&--;` PROPERTY ADDR ACCEPTED BY APPROVING AUTHORITY )NAMES loc,4(- 4ff,j- ADD E S PLANS. INSTALLATION CONFORMS TO ACCEPTED PLANS YES NO. EQUIPMENT USED tS APPRC D E N FILAIN HAS PROPERTY OWNER OR PROPERTY OWNER S AUTHORIZED REPRESENTATIVE 3tzj YES NO BEEN INSTRUCTED AS TO LOCATION OF CONTROL VALVES AND CARE AND MAINTENANCE IS NEW IPM NT PLAIN INSTRUCTIONS HAVE COPIES OF THE FOLLOWING BEEN GIVEN TO THE PROPERTY OWNER OR PROPERTY OWNER'S AUTHORIZED REPRESENTATIVE: 1.SYSTEM COMPONENTS INSTRUCTIONS *-YES NO 2.CARE AND MAINTENANCE INSTRUCTIONS: YES _NO 3. NFPA 35: YES NO LOCATION OF SUPPLIES BLDGS. SYSTEM 11-200 A FLOb2 MAKE MODEL YEAR OF ORIFICE SIZE QUANTITY TEMPERA URE RATING in MANUFACTURE degrees �i�lt7 frf9� Nr• Z u SPRINKLERS vPi(. r o� Z /S PIPE CONFORMS TO / STANDARD YES Lj NO PIPE AND FITTINGS CONFORM TO / STANDARD YES NO FITTINGS IF NO,EXPLAIN ALARM DEVISE MAXIMUM TIME TO OPERATE THROUGH TEST PIPE ALARM VALVE OR TYPE MAKE MODEL MIN. SEC. FLOW INDICATOR SYiteA W .fEf�ShcL. DRY VALVE Q.O.D. MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO. DRY PIPE TIME WATER TIME TO TRIP WATER REACHED TEST TRIP POINT AIR ALARM OPERATED OPERATING TEST THRU TEST PIPE PRESSURE AIR PRESSURE PRESSURE PROPERLY OUTLET MIN. SEC. PSI. PSI. PSI. MIN. SEC. YES NO Without Q.O.D. With Q.O. IF NO,EXPLAIN OPERATION PNEUMATIC ELECTRIC HYDRAULIC DELUGE& PRE- PIPING SUPERVISED I IYES I INO I DETECTING MEDIA SUPERVISED ]YES IN9 ACTION VALVES DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATION YES NO IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT FOR TESTING IF NO,EXPLAIN YES f NO DOES EACH CIRCUIT DOES EACH CIRCUIT MAXIMUMJIME TO MAKE MODEL OPERATE SUPERVISION OPERATE VALVE RELEASE OPERATE RELEASE LOSS ALARM YES I NO YES I NO YES I NO HYDROSTATIC: Hydrostatic tests shell be made at not less than 200 psi(13.6 bars)for two hours or 50 psi(3.4 bars)above static pressure in excess of 160 psi(10.2 bars)for two hours. Differential dry-pipe valve clappers shall be left open during test to prevent TEST damage. All aboveground piping leakage shall be stopped. FLUHING: Flow the required rate until water la clear as indicated by no collection of foreign materiel In burlap begs at outlets such ss DESCRIPTION hydranSts and blow-offs. Flush of flows not lest than 400 GPM(1614 Umin)for 414nch pipe,800 GPM(2211 UM4n)for 5-fnch pipe,750 GPM(2839 Umin)for 124nch pipe.When supply cannot produce stipulated flow rates,obtain maximum available. PNEUMATIC: Establish 40 psi(2.7 bars)air pressure and measure drop which shall not exceed 1 112 psi(0.1 bars)in 24 hours.Test ressure tanks at normal water level and air pressure and measure air suj!p which 0811,101 exceed 1-1/2 psi 0.1 bars in 24 hours. ALL PIPING HYDROSTATICALLY TESTED AT PSI FOR HRS. IF NO,STATE REASON DRY PIPING PNEUMATICALLY TESTED YES I IND EQUIPMENT OPERATES PROPERLY YES NO READING OF GAGE LOCATED NEAR WATER SUPPLY TEST PIPE. RESIDUAL PRESSURE WITH VALVE IN TEST TESTS DRAIN TEST STATIC PRESSURE: PSI � PIPE OPEN WIDE PSI Underground mains and lead in oonneotions to system risers flushed before connection made to s rinkler piping. VERIFIED BY COPY OF THE U FORM NO.858 =YES [:Z]NO OTHER EXPLAIN FLUSHED BY INSTALLER OF UNDER GROUND SPRINKLER PIPING YES NO TANK TESTING NUMBER USED LOCATIONS NUMBER REMOVED AND GASKETS WELDING PIPING YES I I NO IF YES........ DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY WITH THE REQUIREMENTS OF AT LEAST AWS D10.9,LEVEL AR-3 171�:j YES=NO DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED WELDING IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEASTAWS D110.9.LEVEL AR-3 YES tnNO 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 HYDRAULIC DATA NAMEPLATE PROVIDED IF NO.EXPLAIN NAMEPLATE IT3 YES NO DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: REMARKS �Z NAME OF SPRINKLER CONTRACTOR TESTS WITNESSED BY SIGNATURES FOR PRO 9" loli� ;i��PERTY OWNER(SIGNED) TITLE DATE �I 49 v r'!� l FOR SP INKLER CO TRACTOR( NGED) TITLE DATE ADSITIOTIAL EXPL.ANAt ON AND NOTES CONTRACTOR'S MATERIAL. TEST CERTIFICATE FOR ABOVEGROUND PIPING t7mv,.177 77 Upon . .„ `44A leWeG(on andtgsti!ball be made by the Sonlredw's reprusentative and yritnaisad by an ownees representative. All defects shag 4e NIl in"nric►•j ftt i o ntraclari peraonfidl f9r 44,16aye the(ob. by bpth repreyntelI"s Copias#hall be prepared ior_lpptovipp aWhodlift ownsrs end contractor. 11 i 0 rel" n Me Is a.ieQ(tl ory.grn!Ntly pro tewp of the property"nor and that by the property fTs a. ativ�l nature,t1*10=1 9�tKih epts'i�IICT!Don/lblilty(ot the sysllm ea Installed and Agree$ dfilt Cdi61� .i ,dnd: "I;rrd DATE • �0��1�c: r3 S-I EPTE A ). 26)cA P .rfWFtzKTYNWJ4rWWAVT-RQMZFD REPRESENTATIVE YES 6 EN INSTR TED AS CATION `i OL VALVES AND CARE A D INTENANC S NEWEQUIPMENT IF NQ.EAPLAIN ER OR y. ., •. .4 }sROP RTYOWNER•'S.AUTHOR1Z00APPRESENTATiVE: 1.SYST2M COMPONENTS INSTRUCTIONS YkYES _NO 2.t:ARE AND MAINTENANCE INSTRUCTIONS: YES _NO 3. PA-26: 5... 0 LOW SUPPLIES KOGS. /4 MAKE MODEL YEAR RE ORIFIC ZE QUANTITY d C) a In SPIIt KKLERS PIPE CONFORMS TO STANDARD st YES NO PIPE-AND FITTINGS CONFORM TO /'� —STANDARD YES Lj NO FITTINGS IF NO,EXPLAIN ALARM DEVISE MAXIMUM TIME TO OPERATE THROUGH TEST PIPE ALARM VALVE OR TYPE MAKE MODEL MIN. SEC. FLOW INDICATOR .40R VAL Q.O.D. MODEL SERIAL NO.EPOINT MODEL l NO. DRY PIPE TIME TO TRIP WATER AIR PRESSURREACHED TEST ALARM OPERATED O BERA LNG EST uiRl�TEST PIPE P8F•SSURE ;,DUTLET PROPERLY EC. PSI. ` N. SEC. YES NO Whhoul dw a / O.O.D. Win 0.0.0 IF NO.E XPLAIN OPERATION PNEUMATIC I JELE0*0 I HYDRAULIC` DELUGE PRE. PIPING SUPERVISED YES NO DETECTINGMEDIA.SU"E VISER;. YES N0 ACTION VALVES DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATION yi.&-.'_ IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT FOR TESTING IF N0,VPU1fN YES F7NO DOES EACH CIR UM DOES EACH CIRCUIT MAKE MODEL OPERATE SUPERVISION OPERATE VALVE RELEASE OIZELEASIi LOSS ALARM: 1. YES YE 0 HYDROSTATIC: HYdroalallo testa shall be made at not lase then 200 pal(13.1i bare)for two hours or SO pet(3.4 bars)above 81add pressure In axcaas of 1 SO 08100.2 bars)for twn hours.DlRaranllal dry-pipe valve olappars shall be IsB'6 &thing lest to prawl. , ESt damage. All aboveground piping loakage shall be slopped. 9 c.1Xc xy�g�y .1 FLUSHING; F low tho raquirod rate until walar bloat as Indtcalad by no eouoction of foreign matarigl•In bud Ap,bags at euflsU k4h as QG D V fy(Il' i dN hydrants and blow-ONS. Flush al now not less than 400 GPM(f S14 UMIn)for 4-inch p)par S00 OPM;(.W'j tX1#n)for 64nch plus,760 GPM(2830 Umin)for 124nch plpe.When guppy cannot praduoa stipulated new ratan;ebtaln Maximum avatl8bk. PNEUMATIC: Establish 40 pat(2.7 bars)sir pressure and measure drop which shall not exceed 1-V2 psi(0.1 bars)In 24 tours.Tos1 rassura tanks at or al a ar level and e r pressure and sI(.pmgsUqe droo i _ 1, 0. bars in 24 hours. ALL PIPING HYDROSTATICALLY TESTED AT PSI FOR 'HAS. tF N0,S FATE kEASON ORY P!PlNG PNEUMATICALLY tESTED EQUIPMENT OPERATES PROPERLY YES NO READING OF GAGE LOCATED NEAR WATER SUPPLY TEST PIPE. RESIDUAL PRESSURE WI V VE IN TE T TESTS DRAIN TEST STATIC PRESSURE: PSI ' PIPE OPEN WIDE PSI Underground mains and lead in conneollons to system rite ftuahed before connection made to Orinklot piping. VERIFIED BY COPY OF THE U FORM NO.859 =YES [M]NO OTHER EXPLAIN FLUSHED BY INSTALLER OF UNDER GROUND SPRINKLER PIPING YES =NO TANK TESTING NUMBER USED LOCATIONS NI16fBEft`'R" tea AND ONSKETS WELDING PIPING YES I I NO 1F Y RT F A WELDING COMPLY WITH THE REQUIREMENT&&'AT LEAST D10.0.LEVEL AR-3 YESQNO DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED WELDING IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS Di 0.9,LEVEL AR-3 G6 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 NO HYDRAULIC BATA NAMEPLATE PROVIDED IF N0,EXPLAIN NAMEPLATE ( ]YES Q NO DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: RWAAKS NAME OF SPRINKLER CONTRACTOR -~ TESTS WITNESSED BY SIGNA TURES FOR PROPERTY OWNER(SIGNED TITLE GATE 5-W r FM SPRINKLER TRA TOR( INGEO) TITLE DATE 1 ADOITI-ONAL WtANAT tDN AND NOTES CONTRACTOR'S MATERIAL TEST CERTIFICATE FOR ABOVEGROUND PIPING Upon complpti 9i work inapectlon and-tests shall be made by the conlractW3 representative and witnessed by an owner's representative. All defaots shall be oorrs$ted"syNem loft in service baiont contractofs p�sanei finally leave the job. A !;et 11,18 tdletl out And.Iigned by both representatives. Copies MON be prepared for approving authon'das,owners and convector. It is untlrkit0od tt rjoperty owner s euthorizad rsptesenletive is a legal a�rwlory end hiNy reprosOtNall"of the property gynar and that Dy the property owtibYa or propttlly s autitorized'representative'a signature,the property owner acoepts full nisponslWllty for the system as installed and agrees Niiitt Min n d0fic4lift i t'" fe'libi"e vi '.authors .a requiremerts and local ordinaries. PROPERTY DATE �L PROPKIMARDRESS T v�f�lA�l�'To� t�► AC Y APPROVING AU RITY('S}NAMES �0CA � �- D PLANS M ' Ma IS APPR D Y S NO INSTRUCTED BEEN AS TO LOCATION OF CONTROL VALVES AND CARE AND MAINTENANC S NE IPMENT tit;y INS.'RUCT.tQNS' HAW COPIES OF THE 00tLOWING BEEN GIVEN TO THE PROPERTY OWNER OR PROPERTY OWNER'S AUTHORIZED REPRESENTATIVE: i.SYSTEM COMPONENTS INSTRUCTIONS YES NO 2.CARE AND MAINTENANCE INSTRUCTIONS: YES _NO 3. FP ES NO ON'OF SUPPLIES BLDGS. �n YEAR MAKE MODEL �T RE ORIF SIZE QUANTITY d Yt o 1/7— / SPRINKLERS PIPE CONFORMS TO STANDARD ;C YES NO PIPE AND FITTINGS CONFORM TO STANDARD YES NO FITTINGS IF NO,EXPLAIN ALARM DEVISE MAXIMUM TIME TO OPERATE THROUGH TEST PIPE ALARM VALVE OR TYPE MAKE MODEL MIN. SEC. FLOW INDICATOR gkov DRY VALVE MAKE MODEL SERIAL N0. I MAKE MODEL SERIAL NO. DRY PIPE IME A ER Twe TO TRIP WATER AIR PR TRIP DINT Alt TEST ALARM OPERATED OPOWINO"TEST .,,g ,Z�RU TEST,?IPE ..,PI ES�URE , F SOREA�r' UTLET PROPERLY MIN. SEC. PSI. PSI. I. MIN. SEC. YES NO Without Q.O.D. IF NO. XPLAIN OPERATION PNEUMATIC ELECTRIC HYDRAULIC DELUGE& PRE. PIPING SUPERVISED I YES NO I DETECTING MEDIA SUPERVISED YES IND ACTION VALVES DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATION YES NO IS THERE AN ACCESSIBLE FACILITY IN EAC CIRCUIT FOR TESTING IF NO,EXPLAIN YES NO DOES EACH CIRCUIT DOES EACH CIRCUIT MAXIMUM TIME 1`0 OPERATE SUPERVISION MAKE MODEL LOSSALARM OPERATE VALVE RELEASE OPERATE RELEASE YES I NU ES NO YES.. dYDROSTATIC: Hydrostatic tests shall be made at not Idea than 200 pal(13.6 bars)-for two hours or 50 psi(3.4 ban)above static pressure In axceas of 150 pet(10.2 bars)for two hours. Differential dry•plpe valve clappers shall be left open during test to prevent TEST damage. All aboveground piping leakage shall be stopped. FLUSHING: Flow the required rate until water Is clear as Indicated by no collodion of foreign materiel In burlap bags at outlets such as DESCRIPTION hydrants and blow-offs. Flush at flows not lest then 400 GPM(1514 Umin)for 4•ktdt pipe,600 GPM(2271 1./min)for 5-Inch pipe,750 GPM(2839 Umin)for 12-inch pipe.When supply cannot product stipulated flow rates,obtain maximum available. QjJEUMATiC: Establish 40 psi(2.7 bars)air pressure and measure drop which shall not exceed 1-112 psi(0.1 bars)In 24 hours.Tett creature tanks t normal water level and air pressure r to wjhlch shall e j-j/2osI(0.ib4rs)In24houn, ALL PIPING HYDROSTATICALLY TESTED AT PSI FOR HRS. IF NO,STATE REASON DRY PIPING PNEUMATICALLY TESTED ��Ylis ��NO EQUIPMENT PROPERLY YE6 NO READING OF GAGE LOCATED NEAR WATER SUPPLY TEST P11 RESIDUAL PRESSOR I VALVE IN TEST TESTS DRAIN TEST STATIC PRESSURE: PSI PIPE OPEN WIDE PSI Underground mains and lead In connections to system risers Hushed before Connection made to sprinkler piping. VERIFIED BY COPY OF THE U FORM NO.868 =YES ©NO OTHER EXPLAIN FLUSHED BY INSTALLER OF UNDER GROUND ^ e SPRINKLER PIPING-- YES NO TANK TESTING NUMBER USED LOCATIONS NUMBER REMOVED AND GASKETS LSIL WELDING PIPING 71 YES NO IF YES..,..... DO.YOUCERTIFY AS THE SPRINKLER-Q0'NTRACTQR THAT WELDING PROCEDURES COMPLY WITH THE REQUIREMENT$'OF AT LEAST AWS.010.0,LEVEL AR-3, [�YES=NO DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED WELDING IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.9,LEVEL AR-3 [�* .YES NO 00 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 (PING ARE NOT PENETRATED YES=NO N0,EXPLAIN HYDRAULIC DATA NAMEPLATE PROVIDED IF NAMEPLATE [T YES=] NO DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: REMARKS NAME OF SPRINKLER CONTRACTOR TESTS WITNESSED BY SIGNATURES FOR PROPERTYWNER(S N D) TITLE- DATE FSK SP RV4 JKLEIT CONTRACTOR(SINGED) TITLE DATE ADDITIO L EXPLANATION ANb NOTES wow CONTRACTOR'S MATERIAL TEST CERTIFICATE FOR ABOVEGROUND PIPING IR105 11 Upon corr�lelioriolwore,inspection and lesls;shall be made by the conlrscloes representative and witnessed by an owner's representative. All defects$hail be correcttrd:aftdaystem 1011 in service before contractor's personnel finally leave the iob. A certifigata;tgIi he filled out and signed by both.representatives. Copies shall be prepared for approving authorities,owners and contractor. It la understood @Ie p�opeo owzar's authorized representative is a legal signatory and fully representative of the property owner and that by the property W046 or pro' t>wraet's authorized?epreeenteNve'a signature,the property owner accepts full responsibility for the system as installed and agrees At With.""' Aaiics with the a geable a vin ,authori s requirements and local ordinances. DATE, eP.E. ACCEPTED Y APP VIN AUTHORITY )NAMES PLANS . INSTALLATION CONFURMS TO ACCEPTED PLANS El E fP E.7 USED S APPRO ED . YE NO 11A-S PROPERTY OWNER OR PROPERTY OWNER'S AUTHORIZED REPREVENTATIVE ES NO BEEN INSTRUCTED AS TO LOCATION OF CONTROL VALVES AND CARE AND MAI NTE NAN4^41EWEQUIPM NT MUM INSTRUCTIONS HAVE COPIES OF THE FOLLOWING BEEN GIVEN TO THE PROPERTY OWNER OR PROPERTY OWNER'S AUTHORIZED REPRESENTATIVE: 1.SYSTEM COMPONENTS INSTRUCTIONS ES _NO 2.CARE AND MAINTENANCE INSTRUCTIONS: YES _NO 3::NF. b: YES NO LOCAAT ON'OF SUPPLIES B DGS. SY. . . Z Flom- MAKE MODEL MM(UFACTURE ORIFICE SIZE QUANTITY d RE N n !EE e SPRINKLERS PIPE CONFORMS TO STANDARD YES NO PIPE AND FITTINGS CONFORM TO ._ STANDARD YES NO FITTINGS IF NO,EXPLAIN ALARM DEVISE MAXIMUM TIME TO OPERATE THROUGH TEST PIPE ALARM VALVE OR TYPE I MAKE MODEL MIN, SEC. FLOW INDICATOR DRY VALVE Q.0.0. KE MODEL SERIAL NO. MAKE MODEL SERIAL NO. DRY PIPE TIM WATER TIME TO TRIP WATER AIR PRESSURE TRIP POINT AIR REACHED TEST ALARM OPERATED OPERATING TEST THRU TEST PIPE PRESSURE PRESSURE OUTLET PROPERLY MIN, SEC. PSI, PSI, PSI. MIN. SEC. YES NO Without O.O.D With 0.0. IF NO,EXPLAIN took OPERATION PNEUMATIC I ELECTRIC I HYDRAULIC DELUGE& PRE- PIPING SUPERVISED YES I NO I DETECTING MEDIA SUPERVISED I YES I NO ACTION VALVES DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATION YES I NO IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT FOR TESTING IF NO,EXPLAIN YES NO DOES EACH CIRCUIT DOES EACH CIRCUIT MAXIMUM TIME TO OPERATE SUPERVISION MAKE MODEL LOSS ALARM OPERATE VALVE RELEASE OPERATE RELEASE wk YES I ' NO YES NO YES NO HYDROSTATIC: Hydrostatic tests shall be made at not less then 200 psi(13.6 bars)for two hours or 50 psi(3A bars)above static pressure in excess of 150 psi(10.2 bars)for two hours. Differential dry-pipe valve clappers shall be left open during lest to prevent TEST damage. All aboveground piping leakage shall be stopped. FLUSHING: Flow the required rate until water is Gear as indicated by no collection of foreign material in burlap bags at outlets such as DESCRIPTION hydrants and blow-offs. Flush at flows not less then 400 GPM(1514 Umin)for 44nch pipe,600 GPM(2271 Umin)for 5-Inch pipe,750 GPM(2830 Umin)for 124neh pipe.When supply cannot produce stipulated flow rates,obtain maximum available. PNEUMATIC: Establish 40 psi(2.7 bars)air pressure and measure drop which shell not exceed 1-1/2 psi(0.1 bars)In 24 hours. Test ressure tanks at normal water level and air pressure and measure air pressure droo which shall not exceed 1-112 ozi 0.1 barsl In 24 hours, ALL PIPING HYDROSTATICALLY TESTED AT SI FOR HRS. IF NO,STATE REASON DRY PIPING PNEUMATICALLY TESTED YES NO EQUIPMENT OPERATES PROPERLY YES NO READING OF GAGE LOCATED NEAR WATER SUPPLY TEST PIPE. RESIDUAL PRESSURE WITH VALVE IN TEST TESTS DRAIN TEST STATIC PRESSURE: PSI ' PIPE OPEN WIDE �jp 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.868 =YES ©NO OTHER EXPLAIN FLUSHED BY INSTALLER OF UNDER GROUND 0% J` e SPRINKLER PIPING YES N TANK TESTING NUMBER USED LOCATIONS NUMBER REMOVED AND GASKETS 61 � WELDING PIPING YES I I NO IF YES........ 00 YOUCERTIFY AS THE SPRINKLER-CONTUC-TOR THAT WELDING PRO EDU S COMPLY WITH THE REQUIREMENTS OF AT LEAST AWS D10.9,LEVEL AR-3 17-9q YES=NO 60 YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED WELDING IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS 010.9,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 PENET ED Y N HYDRAULIC DATA NAMEPLATE PROVIDED rNO.EXPLAIN NAMEPLATE 1W YES= No DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: REMARKS NAME OF SPRINKLER CONTRACTOR TESTS WITNESSED BY P OPE W ER(S D) TITLE DATE SIGNATURES OR ��mG -�s wI ye F IN TRACT (SIN TITLE DATE y ADDITIbNAL EXPLANATION AND NOTES CONTRACTOR'S MATERIAL. TEST CERTIFICATE FOR ABOVEGROUND PIPING fills PROCEDURE R� Upon completion of work,inspection and tests shall be made by the contractors representative and witnessed by an owner's representative. All defects shall be corrected and system left in service before contractor's personnel finally leave the job. A oertifl;We shall be filled out and signed by both representatives. Copies shall be prepared for approving authorities,owners and contractor. It is understood the properly owners authorized representative is a legal signatory and fully representative of the property owner and that by the properly owners or propAtty owners authorized representative's signature,the property owner accepts full responsibility for the system as Installed and agrees that it 19 in oom lancewith the applicable approving authority s requirements and local ordinances. PROPERTY NAME / DATE e � ,TJ� j r/ PR ER- ADDRESS Q`J t ! .� rah ACCEPTED BY APPROVING AUTHORITY('S)NAMES Affffff-EIS PLANS INSTALLATION CURFMM TO ACCEPTED PLANS YES H. 76— E. .IPME T SED IS APPROVED YE NO HAS PR57MrF?T1WNER OR PROPERTY OWNER'S AUTHORIZED REPRESE „ E N BEEN INSTRUCTED AS TO LOCATION OF CONTROL VALVES AND CARE AND MAINTENANC S YNE S IPMENT XPLAIN INSTRUCTIONS HAVE COPIES UF THE FOLLOWING BEEN GIVEN TO THE PROPERTY OWNER OR PROPERTY OWNER'S AUTHORIZED REPRESENTATIVE: 1.SYSTEM COMPONENTS INSTRUCTIONS ES _NO 2.CARE AND MAINTENANCE INSTRUCTIONS: YES _NO 3. NFPA 25: YES NO LOCATION OF SUPPLIES B_.DGS. SYSTEM N'j Ft/#OA- MAKE MODEL YEAR OF ORIFICE SIZE QUANTITY TEMPERATURE NG in MANUFACTURE Z degrees 0 SPRINKLERS MgMAL PIPE CONFORMS TO �-- _STANDARD YES NO PIPE AND FITTINGS CONFORM TO * —I__STANDARD YES NO FITTINGS IF NO,EXPLAIN ALARM DEVISE MAXIMUM TIME TO OPERATE THROUGH TEST PIPE ALARM VALVE OR TYPE MAKE MODEL MIN. SEC. FLOW INDICATOR DRY VALVE Q.O.D. MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO. DRY PIPE TIME WATER TIME TO TRIP WATER TRIP POINT AIR ALARM OPERATED OPERATING TEST THRU TEST PIPE PRESSURE AIR PRESSURE PRESSURE REACHED TEST PROPERLY OUTLET MIN. SEC. PSI, PSI. PSI. MIN. SEC. YES NO Without 0.0.0, With 0.0.0 IF NO,EXPLAIN I OPERATION PNEUMATIC ELECTRIC HYDRAULIC DELUGE& PRE. PIPING SUPERVISED I YES I NO I DETECTING MEDIA SUPERVISED YES NO ACTION VALVES DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATION I YES I NO IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT FOR TESTING IF NO,EXPLAIN YES NO GOES FACHCIRCUIT DOES EACH CIRCUIT MAXIMUM TIME fO OPERATE SUPERVISION MAKE MODEL LOSS ALARM OPERATE VALVE RELEASE OPERATE RELEASE YE NO, 7E7 NO N HYDRO. TIC: Hydrostatic lasts shall be made at not Was:Mien 200 psi(13.8 bite)-6r two tours or 50 psi(3A beta)above statio pressure in excess of 150 psi(10.2 ban)for two hours. Differential dry-pipe valve clappers shall be W open during lest to prevent TEST damage. All aboveground piping leakage ahan bs slopped. FLUSHING: Flow the required rate until water it clear as indicafad by no collection of foreign material in burlap bags st outlets such" DESCRIPTION hydrants end blow-offs. Flush at flows not leas than 400 GPM(1514 Umin)for 4-Inch pipe,800 GPM(2271 U1min)for S-Inch pipe,760 GPM(2630 Umin)for 124mch pipe.When supply cannot produce stipulated flow rates,obtain maximum avai4bia. PNEUMATIC: Establish 40 psi(2.7 bets)air pressure and measure drop which shall not exceed 1-1t2 psi(0A bars)in 24 hours.Test assure tanks at normal water level and air pressure and measure alt pressure drop which shall note d 1- 0.1 r3)in 4 ALL PIPING HYDROSTATICALLY TESTED AT SI FOR HRS. IF NO,STATE REASON DRY PIPING PNEUMATICALLY TESTED YES NO EQUIPMENT OPERATES PROPERLY YES NO READING R MCArprl NEAR WATER SUPPLY TEST PIPE. RESIDUAL PRESSURE WITH VALVE IN TEST TESTS DRAIN TEST STATIC PRESSURE: PSI < PIPE OPEN NOE 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.858 [=YES r JrjNO OTHER EXPLAIN FLUSHED BY INSTALLER OF UNDER GROUND SPRINKLER PIPING =YES NO TANK TESTING NUMBER USED LOCATIONS NUMBER REMOVED AND GASKETS lI & WELDING PIPING YES I NO IF YES...,..., O YZ5U RTIP?AS THE SPRINKLER CONTRACTOR THAT WELDING R CEDU S COMPLY WITH THE REQUIREMENTS OF AT LEAST AWS D10.0,LEVEL AR-3.. YES QNO DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED WELDING IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS 010.0,LEVEL AR-3 Q ].YES=NO 00 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 HYDRAULIC DATA NAMEPLATE PROVIDED IF NO,EXPLAIN NAMEPLATE [K]YES No DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: REMARKS NAME OF SPRINKLER CONTRACTOR ar t TESTS WITNESSED BY SIGNATURES 0 RO RTY OWN R(SI NED) TITLE DATE R LER NTRA OR SINGED TITLE DATE ADbITIONAL E PLANATION AND NOTES ✓'l CONTRACTOR'S MATERIAL TEST CERTIFICATE FOR ABOVEGROUND PIPING P RO OR Upon Completion of work,inspection and tests;hall be made by the contractors representative and witnessed by an owner's representative. Ali defects shall be corr"W.andayatam left in service before contractors personnel finally leave the job. A certI iratesllall tts 611ed out and signedby both representatives. Copies shall be prepared for approving authorities,owners and contractor. It Is undpatdod the psb*0 owners authorized representative Is a 10941 signatory and fully representative of the property owner and that by the property owners or prop(wl&� it W3 a'uthorized'representative's signature,the property owner accepts full responsiblilly for the system ea Installed end agrees thahit tiro '' ie ice with the• licable 'fovin .suthpri s requirements and local ordinances. S DATE. �dN 4 P E BY APPROVING AUT 0 ITY(' ) A �aC4 P\r, ADDRESS ADDRESS PLANS . *E1 Z�T E IS APPROVED Y E ;NFPAUPERTY OWNER OR PROPERTY OWNER'S AUTHORIZED RIEPRE3ENTATIVE I NO HAbVK .25 STRUCTED AS TO LOCATION OF CONTROL VALVES AND CARE AND MAINTENANC NE IPM NT EAPLAIN INSTRUCTIONS OPIES OF THE-FOLLOWING BEEN GIVEN TO THE PROPERTY OWNER OR RTY OWNER'S AUTHORIZED REPRESENTATIVE: EM COMPONENTS INSTRUCTIONS ES _NO AND MAINTENANCE INSTRUCTIONS: YES —N : YES NO LOCATION'OF SUPPLIES BLDGS. SY T,:IR�VI 3'`b IGtxv2 MAKE MODEL YEAR OF ORIFICE SIZE QUANTITY TEMPER T RE N n MANUFACTURE d egress i Z„ SPRINKLERS PIPE CONFORMS TO STANDARD YES NO PIPE AND • FITTINGS CONFORM TO . STANDARD YES NO FITTINGS IF NO,EXPLAIN ALARM DEVISE MAXIMUM TIME TO OPERATE THROUGH TEST PIPE ALARM VALVE OR TYPE I MAKE MODEL MIN. SEC. FLOW INDICATOR DRY VALVE O.O.D. MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO. DRY PIPE TIME WATER TIME TO TRIP WATER TRIP POINT AIR ALARM OPERATED OPERATING TEST THRU TEST PIPE PRESSURE AIR PRESSURE PRESSURE REACHED TEST PROPERLY OUTLET MIN. I SEC. PSI. PSI. PSI, MIN SEC. YES NO Without 0.0.0. With 0.0.0 IF NO,EXPLAIN CONTRACTOR'S MATERIAL. TEST CERTIFICATE FOR ABOVEGROUND PIPING Upon domOTellon btwotK inspection end lest;.;ihall be made by the contractors representative and witnessed by an owners representative. All defects shall be cortapted<endeiratem left in service b6f."O,owriptoes personnel Melly leave the job. A GeriNj a a110.a Etied nut and aiyned by hoth.roproaentativos. Copies shed be prepared for epprovinp authorities,ownero and contractor. IIdcQ `ffG ormer3 eVRhotlzerl rsprelentetive la a ICpet alpnettiry:and Nllyreprea9rltallvo of the property owner and that by the property ra authorized fOptlibntttb7s'e alynaturs,SAe¢robN4y OV4rsbf'aeoapb iv{{r��poifdbillly for!rte system as Installed an0 spree `.K" w I ,a ro vlromanta end f kordlnaipes. at.KIt,r' a�-i+dtlt ths:e Ilatile "` v PROF DATE. Rr RPM ACCEPTED• r BY APPROVING AUTHORITY )NAMES Z0 Yr 1 T U E0 S APPRO EO PtP 41S BEEN INSTRUCTED AS TO LOCATION OF CCN ROL VALVES AND CAR AND MAINTENANC S NE IPMEONT INS IOTIO.N$ . HAV EN GIVEN TO THE PROPERTY OWNER OR PROP RTY OWNER'S AUTHORIZED REPRESENTATIVE: t.SYSTEM COMPONENTS INSTRUCTIONS ES _NO 2.CARE AND MAINTENANCE INSTRUCTIONS: YES _„NO YE3 NO :LOC'. W . IES BLDGS. MAKE MODEL YEAR T ORIFICE SIZE QUANTITY n UFACyRE d roes a ,4 phi SPRINKLERS PIPE CONFORMS TO STANDARD YES NO PIPE AND FITTINGS CONFORM TO STANDARD YES NO FITTINGS IF NO,EXPLAIN ALARM DEVISE MAXIMUM TIME TO OPERATE THROUGH TEST PIPE ALARM VALVE OR TYPE MAXE I MODEL MIN. SEC. FLOW INDICATOR t► ATM AAM DRY VALVE Q.O.D. KE MODEL SERIAL.NO. MAKE MODEL SERIAL N0. 1 WA ER DRY PIPE TIME TO TRIP WATER AIR PRESSURE TRIP POINT AIR REACHED TEST ALARM OPERATED OPERATING TEST THRU TEST PIPE PRESSURE PRESSURE OUTLET PROPERLY MIN. SEC. I PSI. PSI. PSI. MIN. SEC. YES NO Withovl 0.0.0. With D.O.D IF N0,EXPLAIN C,ONSIC-ILI LICENSED BUILDER FINAL AFFIDAVIT To the Inspectional Services Commissioner: I certify that 1, or my authorized representative, have inspected the work associated with Permit No. BP-2014-1012, dated 4/04/2014 locus Smith College ward Cutter-Ziskind - Phase 2 (on the dates used below), and that to the best of my knowledge, information, and belief the work has been done in conformance with the permit and plans approved by the Inspectional Services Department and with the provisions of the Massachusetts State Building Code and all other pertinent laws and ordinances. Stephen Miers-CS-019643 LICENSED BUILDER-LICENSE NO. Consigh Construction Company, Inc. COMPANY 72 Sumner St., Milford, MA 01757 ADDRESS 508-458-0487 PHONE Inspection Dates: August 151h, 201 Then personally appeared the above-named I �� and made oath that the above statement by he he is true. Before me, M c In ission expires I 1 V,'e '9`s- 20I Consigli Construction Co.,Inc. Construction Managers and General Contractors ** Fire Alarm Affidavit Discipline: Fire Alarm Date: August 13th, 2014 Project: Cutter-Ziskind House Renovation— Smith College, 79 Elm St. Permit No.: BP-2014-1012 To: Louis Hasbrouck, Building Commissioner Puchalski Municipal Building, 212 Main Street, Northampton, MA 01060. I certify that I, or my authorized representative, have reviewed the work associated with Permit No. BP-2013-1253 for Cutter-Ziskind House Renovation, 79 Elm Street, Northampton, MA, for Smith College (on the dates used below or on at least 5 occasions during construction), and that to the best of my knowledge, information, and belief, the work has been done in conformance with the permit, and in conformance with the provisions of CMR 780, Chapter 116.2.2 and with the provisions of the Massachusetts State Building Code and all other pertinent laws and ordinances. 47842 Massachusetts Registration No. low Arup Company 955 Massachusetts Avenue �ytH OF A% MwREW 0. Cambridge, MA 02139 Address FIRE u PROTECTION NO.47U2 TE� (617) 349-9295 Telephone Seal: Andrew B.Woodward OPW Fire Protection Affidavit Discipline: Fire Protection Date: August 13th, 2014 Project: Cutter-Ziskind House Renovation— Smith College, 79 Elm St. Permit No.: BP-2014-1012 To: Louis Hasbrouck, Building Commissioner Puchalski Municipal Building, 212 Main Street, Northampton, MA 01060. I certify that I, or my authorized representative, have reviewed the work associated with Permit No. BP-2013-1253 for Cutter-Ziskind House Renovation, 79 Elm Street, Northampton, MA, for Smith College (on the dates used below or on at least 5 occasions during construction), and that to the best of my knowledge, information, and belief, the work has been done in conformance with the permit, and in conformance with the provisions of CMR 780, Chapter 116.2.2 and with the provisions of the Massachusetts State Building Code and all other pertinent laws and ordinances. 47842 Massachusetts Registration No. Arup Company 955 Massachusetts Avenue SNOF Cambridge, MA 02139 y� Address ANDREW 9 FIRE V PROTECTION (617) 349-9295 NO.478Q A Telephone �G/STE g�13 /1 Seal: Andrew B.Woodward Plumbing Affidavit Discipline: Plumbing Date: August 8th, 2014 Project: Cutter-Ziskind House Renovation— Smith College, 79 Elm St. Permit No.: BP-2014-1012 To: Louis Hasbrouck, Building Commissioner Puchalski Municipal Building, 212 Main Street, Northampton, MA 01060. I certify that I, or my authorized representative, have reviewed the work associated with Permit No. BP-2013-1253 for Cutter-Ziskind House Renovation, 79 Elm Street, Northampton, MA, for Smith College (on the dates used below or on at least 5 occasions during construction), and that to the best of my knowledge, information, and belief, the work has been done in conformance with the permit, and in conformance with the provisions of CMR 780, Chapter 116.2.2 and with the provisions of the Massachusetts State Building Code and all other pertinent laws and ordinances. 49296 #Poll Massachusetts Registration No. Arup Company �o'OoLTH Or 4f 955 Massachusetts Avenue Wq�s qRK sue'° MFCyq Cqp,,� Cambridge, MA 02139 o �H, 2/Cq� y Address 49 9s 7'E G,O�C�'`, (617) 349-9228 Telephone Seal Mark Walsh-Cooke Electrical Affidavit Discipline: Electrical Date: August 8th, 2014 Project: Cutter-Ziskind House Renovation— Smith College, 79 Elm St. Permit No.: BP-2014-1012 To: Louis Hasbrouck, Building Commissioner Puchalski Municipal Building, 212 Main Street, Northampton, MA 01060. I certify that I, or my authorized representative, have reviewed the work associated with Permit No. BP-2013-1253 for Cutter-Ziskind House Renovation, 79 Elm Street, Northampton, MA, for Smith College (on the dates used below or on at least 5 occasions during construction), and that to the best of my knowledge, information, and belief, the work has been done in conformance with the permit, and in conformance with the provisions of CMR 780, Chapter 116.2.2 and with the provisions of the Massachusetts State Building Code and all other pertinent laws and ordinances. 45455 Massachusetts Registration No. Arup Company 955 Massachusetts Avenue AAA A Cambridge, MA 02139 3F MASSgCyG�'MOT Address j p.5 G RNA S`' "' t. (617) 349-9230 o E�-1No•�545 /0 Telephone v,o �FGIS'f��1 FFSS10 Seal: Mechanical Affidavit Discipline: Mechanical Date: August 8th, 2014 Project: Cutter-Ziskind House Renovation— Smith College, 79 Elm St. Permit No.: BP-2014-1012 To: Louis Hasbrouck, Building Commissioner Puchalski Municipal Building, 212 Main Street, Northampton, MA 01060. I certify that I, or my authorized representative, have reviewed the work associated with Permit No. BP-2013-1253 for Cutter-Ziskind House Renovation, 79 Elm Street, Northampton, MA, for Smith College (on the dates used below or on at least 5 occasions during construction), and that to the best of my knowledge, information, and belief, the work has been done in conformance with the permit, and in conformance with the provisions of CMR 780, Chapter 116.2.2 and with the provisions of the Massachusetts State Building Code and all other pertinent laws and ordinances. 49296 Massachusetts Registration No. Arup Company o� 'tNvTH OF,ygs 955 Massachusetts Avenue p 4r o� wALSH�K E ME EKE ca g Cambridge, MA 02139 9 0.49 96AL y~ Address 1 01, NA (617) 349-9228 Telephone Seal: Mark Walsh-Cooke Structural Affidavit Discipline: Structural Date: August 8th, 2014 Project: Cutter-Ziskind House Renovation—Smith College, 79 Elm St. Permit No.: BP-2014-1012 To: Louis Hasbrouck, Building Commissioner Puchalski Municipal Building, 212 Main Street, Northampton, MA 01060. I certify that I, or my authorized representative, have reviewed the work associated with Permit No. BP-2013-1253 for Cutter-Ziskind House Renovation, 79 Elm Street, Northampton, MA, for Smith College (on the dates used below or on at least 5 occasions during construction), and that to the best of my knowledge, information, and belief, the work has been done in conformance with the permit, and in conformance with the provisions of CMR 780, Chapter 116.2.2 and with the provisions of the Massachusetts State Building Code and all other pertinent laws and ordinances. 41770 Massachusetts Registration No. Arup Company 955 Massachusetts Avenue Cambridge, MA 02139 Address (617)349-9239 Telephone ESN OF JIMMY C. fs 129'• No.0770 Seal: '$ F I � N 4W Jimmy C. Su The responsibilities of the Owner and Contractor for security,maintenance,heat.utilities,damage to the Work and insurance shall the as follow (dote:(hwier's anti C'twir'actur'.c legal am/insurance cotrrrsel sbou/c/t/eterrrtilre an(/review insivwvice repia•ernt.,Ius awl caeerage.t AIA Document G704r"'—2000.Copyright>8 1963,1978,1992 and 2000 by The American Institute of Architects.Ali rights reserved.WARNING:This AIA' Document is protected by U.S.Copyright law and International Treaties.Unauthorized reproduction or distribution ofthis AIA'"Document,or any 2 portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law.This document was produced by AIA software at 11-29:51 on 08115/2014 under Order No.9884299811_1 which expires on 12131/2014,and is not for resale. User Notes: (862139745) Document G704 T11 - 2000 Certificate of Substantial Completion PROJECT: PROJECT NUMBER: 154059/ OWNER:❑ (Marne a;id ar/d;'•ess) CONTRACT FOR:General Construction Smith College:Cutter-Ziskind House CONTRACT DATE:November 1,2012 ARCHITECT: Renovation CONTRACTOR:❑ Northampton,MA TO OWNER: TO CONTRACTOR: FIELD.❑ (Vame and address) (A'crnre and address) OTHER:❑ The Trustees of Smith Consigh Construction Company 126 West Street 72 Summer Strut Northampton,MA 01063 Milford.Connecticut PROJECT OR PORTION OF THE PROJECT DESIGNATED FOR PARTIAL OCCUPANCY OR USE SHALL INCLUDE: The project involves the complete renovation of the existing 3 story,65,680gsl'CLitter and Z.iskind residences and the connecting dining hall.associated kitchen and two small additions on the wings of the first Floor. The project scope includes Architectural. Civil.Landscape and MEP-FP system upgrades.The project was done over two summers. Phase 2 occurred from May 2014 to August 2014 when the building was unoccupied. The scope of work included demolition and new construction of the following: First Floor exterior envelope,the first floor public spaces south of gridline F.second and third floor residence rooms and bathrooms,and all sitework. Work on all floors are now substantially complete and can be fully occupied.All egress,lifesal'ety and environmental systems are in place for occupancy. The Work performed under this Contract has been reviewed and found,to the Architect's best knowledge,information and belief'. to be substantially complete.Substantial Completion is the stage in the progress of the.Work when the Work or designated portion is sufficiently complete in accordance with the Contract Documents so that the Owner can occupy or utilize the Work for its intended use.The date of Substantial Completion of the Project or portion designated above is the date of issuance established by this Certificate,which is also the date of commencement of applicable warranties required by the Contract Documents.except as stated below: Warranty D to of Commencement All Phase 2 work 0 /15/2014 Perkins+W ill 08/15/2014 ARCHITECT Y DATE OF ISSUANCE A list of items to be completed or corrected is attached hereto.The failure to include any items on such list does not alter the responsibility of the Contractor to complete all Work in accordance with the Contract Documents.Unless otherwise agreed to in writing,the date of commencement of warranties for items on the attached Iist will be the date of issuance of the final Certificate of Payment or the date of final payment. Cost estimate of Work that is incomplete or defective:So.00 The Contractor will complete or correct the Work on the list of items attached hereto within Zero(0)days from the above date of Substantial Completion. CONTRACTOR BY DATE The Owner accepts the Work or designated portion as substantially complete and will assume full possession at (time)on (date). OWNER BY DATE elk AIA Document 13704TM—2000.Copyright®1963,1978,1992 and 2000 by The American Institute of Architects.All rights reserved.WARNING:This AIA' Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this AIA''Document,or any portion of it,may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law.This document was produced by AIA software at 11:29:51 on 08/15/2014 under Order No 9884299811 1 which expires on 1213112014,and is not for resale. User Notes: (862139745) P E R K I N 5 + W I L L Initial Construction Control Document To be submitted with the building permit application by a d Registered Design Professional t for work per the 8th edition of the Massachusetts State Building Code, 780 CMR, Section 107.6.2 Project Title: Smith College: Cutter-Ziskind House Renovation Date: August 6,2014 Property Address: 79 Elm Street,Northampton,MA 01063 Project: Check(x)one or both as applicable: New construction x Existing Construction Project description: The project consists of the renovation of the existing three-story dormitory wings,the existing one-story connecting structure and the basement.The project scope includes residential sleeping units,the dining facility,and some common spaces throughout the building.This work has resulted in construction of site utilities serving building,exterior building envelope replacement,interior fit-up,accessibility upgrades and MEP-FP-Tel-Data system upgrades. I Dana Anderson MA Registration Number:305)QExpiration date:"31 m a registered design professional, and hereby certify that I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning': Entire Project X Architectural Structural Mechanical Fire Protection Electrical Other: #Okr the above named project and that such plans, computations and specifications meet the applicable provisions of the Massachusetts .ate Building Code,(780 CMR),and accepted engineering practices for the proposed project. I understand and agree that I(or my designee)shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept,shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent comments,in a form acceptable to the building official. Upon completion of the work, I shall submit to the building official a `Final Construction Control Document'. Enter in the space to the right a"wet"or � � Autry q a � electronic signature and seal: s' T ` h „,A Phone number: 617.406.3420 Email: Dana.Anderson @PerkinsWill.com Building Official Use Only ,uilding Official Name: Permit No.: Date: Note 1.Indicate with an`x'project design plans,computations and specifications that you prepared or directly supervised.If`other' is chosen, provide a description. Trial Version 10 09 2012 Northampton Fire Department 26 Carlon Drive, Northampton, Massachusetts 01060-2373 Telephone: (413) 587-1032 Fax: (413) 587-1034 Fire Prevention/Operations Officer: Duane A. Nichols Deputy Chiefs:Dana Cheverette, David Gagne, William Hurley and Timothy McQueston Brian P. Duggan Yowl Fire Chief FIRE SUPPRESSION WORK PERMIT Facility Name &Address:5&1 A egcx*66' evrTE,4 Zso iwdl 1Dbgw1ra1__-j Owner's Name & Address: „faZ-fA 7 Contact Person .71-07 Phone# 53 4, -9 Z Z Z Company /Technician performing work:aA0r1ji6rti&1" Ma.Lic. # JC Go/70 2 IYk5w4W144c Dates of work is to be done: / From: 5_131117 To: f3//ShY Description of suppression work to be performed: -o,2y6rAc.G ./f FIR _ . Aiarm.Connection 111..Listed Central Station Name,/°Location: R" t.connecVon via digital dialer Account Contractors performing work must notify Central Dispatch(413-587-1030)at the start of each work session,and when work is finished,or when work is finished for the day.An electrical work permit must be obtained from the Electrical inspector(413-587-1244) Fire Suppression Work Permit Fee $80.00 Paid: Receipt Number: _ Approved By Date "Professionalism through Courage and Dedication" CITY'OF NORTHAMPTON,MASSACHUSETTS DEPARTMENT OF PUBLIC WORK$ 125 Locust Street Trench Permit Number: Northampton,MA 0161) 413.587-1670 bate Approved: G Fax 413-587-1576 Revised Expiration Date: (for City Use Only) y EXCAVATIONfOENCH PERMIT EXTENSION REQUEST Pursuant to G.L.c.82A and 520 CUR 14.00 et seq.(as amended) - i This permit extension)request must be fully completed prior to consideration.Submit completed. to Northampton Department of public Works,125 Locust Street,Northampton,MA 01060. l This permit extension is issued under the paovisions of M.G,L.c.82A,520 CMR 14.00 and applicable sections of the Revised Ordinances of the City of Northampton,including,but not limited to,Section 285-21. It is subject to all the same requirements and regulations that are required in the original permit and as amended as conditions of this permit extension. By signing this form,the applicant acknowledges that he/she has read and understands all the information set forth in and referenced within this application package and that they agree to comply in all respects with the requirements therein. Issued Trench Permit Number ' 2014-331 Name ofApplicant Primary Phone# Gagliarducci construction Inc 413 543-6978 Street Address -Emergency Phone# t 295 Pasco Rd city/Town State Zip Email Springfield MA 01151 info@gagliarducci.com Elrplanation of reason for request for permit extension. Initial trench permit was for investigative test pits. Extension would be for installation of chilled water lines across Elm St. Projected Completion Date: Dig Safe# 5/20/14 to 8/1/14 2014-1916100 & 2014-1916120 Digitally signed by Steven Follett Steven Follett "c Steven Follett,o=Gagllarducci Applicant Signature Construction,Inc.,ou=Project Manager, em�EtOGett @gagliarducci.com,c--us Date:2014.05.1214:58:27-04'00' For City Use--Do not write in this section All work is the City ROW shall cease by November 15th or the onset of winter Conditions of'Approval: conditions,whichever occam first:Work on private property may continue beyond this date.Except for emergencies,arty subsequent excavation in the City ROW will permit Approval require a new permit to be applied for after March 15th of the following year. 1 ' ec#o afP b'c Works PUN I,E=avationfrrench PamttExtension Request S Cf 13-,r};. - P�isr� (o��t�� `1� -- MASSACHUSETTS UNIFORM APPLtCAT10N FOR A PERMIT TO PERFORM GAS FITTING WORK � t CITY —� °"� MA. DATE �3^ ', )-bl.3 PERMIT 4-5�(� JOBSITE-ADDRESS OWNER S NAME��P OWNERADDRESS: Lr l s TEL: Yf5-J7T.r�" � y_da�FAX- TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL,9 RESIDENTIAL M' ,PMT CLEARLY NEW:El RENOVATION: E REPLACEMENT:❑ PLANS SUBMITTED; YES[D NO❑ FIXUTRESI FLOOR- Bsmt 1 2 3 4 5 6 7 . 8 9 1D 11 12 13 14 BOILER BOOSTER- CONVERSION BURNER COOK STOVE a, DIRECT VENT HEATER DRYER. (P FIREPI.AOE. FRYOLATOR FURNACE GENERATOR SrOC 1 GRILLE LABORATORY C KS MAKEUP AIR UNI ti OVEN 7 POOL HEATER ROOM/SPACE MATES TOP UNIT �F-6r «� UNIT HEATER UNVENTED.R T WATER HEATED / INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES C9 NO ❑ If you have checked YES,please indicate the type of coverage by checking fhe appropriate box below. REC E IVI D LIABILITY INSURANCE POLICY ® OTHER TYPE INDEMNITY ❑ BOND ❑ MAR 2 8 j() 3 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws, PLUMBERIGASFITTERNAME; 10110vd S. McOoNN a LICENSE# M }a SIGNATURE f� .'ANY NAME: _cn. . tYl cwt _ C ADDRESS: - _ r3 PTY: 14A ellviII .._-- STATE: [6A Zip: FAX: TEL: �r,�t , a� .3 5 _CELL: _ � EMAIL: j Gc?Y�r r MASTER N JOURNEYMAN❑ LP INSTALLER❑ CORPORATION 9#�PARTNERSHIP❑ LLC❑#{^ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK MA. . DATE �_3 PERMIT`# JOBSITE ADDRESS G>< Lt I y�.-o ��OWNER'S NAME th,Lt OWNERADDRESS: C)^► TEL y! f8 -t`/vp FAX t TYPR OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL RESIDENVALia PRINT CLY-ABLY NEW:❑ RENOVATION:® REPLACEMENT;❑ PLANS SUBMITTED: YESM NO❑ FIXUTRES 1 FLOORS--+ asmt 1 2 3 4 5 6 7 8 9 i4 ii i2 13 i4 BATHTUB CROSS CONN DEVICE J DEDICATED SPECIAL WASTE SYS DEDICATED GASIOIUSAND SYS DEDICATED GREASE SYSTEM 8Yr DEDICATED GRAY WATER SYS DEDICATED WATER.REUSE SYS DISHWASHER DRINKING FOUNTAIN FOOD WASTE GRINDER'UNIT CA FLOOR I AREA DRAIN 3 INTERCEPTOR INTE OR t 4P KITCHEN SINK 3 LAVATORY ROOF DRAIN j `WER STAR a �rtVICEI MOP AK 4 3 fOiLET URINAL WASHING MACH N E TIO WATER HEATE P S WATER PIPING 3 4¢ ,JJ�h t• I r+7 JJ^h 3 INSURANCE COVERAGE I have a current liability Insurance policy or its substantial-equivalent which meets the requirements of MGL.Ch.142 YES M NO ❑ If you have checked YES,please-indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY K OTHER TYPE INDEMNITY ❑ BOND ❑ KAR ?- OWNEWS INSURANCE WAIVER:lam aware that the licensee does not have the tnsurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby m*that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my. Knowledge and that all plumbing work and installations performed under the pem-A issued for this application will be fa compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 418ER NAME: %100 v%,atk JILICENSEW M gag I USIONATQRE COMPANY NAME: ADDRESS: !�5�uAil1 St��tet TY: laay�d2ry1{_('._.- --- — STATE: 7JP: a FAX.Hr3•a - TEI-*T e"tb��aTS _ CELL EMAIL MASTER.0 JOURNEYMAN❑ CORPORATION A mk_.PARTNERSHIP❑A= LLC❑�� 79 ELM ST- ZISKIND/CUTTER EP-2013-0650 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Map: 31 B Lot:201 ELECTRICAL PERMIT Permit: Electrical Category: Wire renovations to Cutter&Ziskind buildings Permit# Electrical PERMISSION IS HEREBY GRANTED TO: Project# JS-2013-001320 Est.Cost: Contractor: License. Fee: $6210.00 UNIVERSAL ELECTRIC CO, INC Master 14149A Owner: Smith College Applicant: UNIVERSAL ELECTRIC CO, INC AT. 79 ELM ST-ZISKIND/CUTTER Applicant Address Phone Insurance 59 B Observer Street (413) 788-9473 Liability, CBP8819383 SPRINGFIELD MA01104 ISSUED ON.•312212013 0:00:00 TO PERFORM THE FOLLOWING WORK: Wire renovations to Cutter&Ziskind buildings Call In Date: Date Requested Inspection Date/SignOff• Reinspect?: Trench/UG• Special Instructions X Roueh X Special Instructions: Final: SRE Called In: Si ature• Fee Type:: Amount: DatePaid Electrical $6210.00 3/22/2013 0:00:00 3192 212 Main Street,Phone(413)587-1244,Fax(413)587-1272-Inspector of Wires -Roger Mato Final Construction Control Document = To be submitted at completion of construction by a Registered Design Professional 4 for work per the 8°i edition of the Y Massachusetts State Building Code,780 CMR, Section 107 Project Title: Smith College_Campus Center Cafe Renovation Date: 26 August t 2014 Permit No,2014-1264 Property Address: 100 Elm Street,Northampton,MA 01063 Project: Check(x)one or both as applicable: New construction X Existing Construction Project description: Interior cafe back of house renovation and addition I Vince Pan MA Registration Number: 20568 Expiration date: 08/31/2014 , am a registered design professional, and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: X Architectural Structural Mechanical Fire Protection Electrical Other:Describe for the above named project. I, or my designee,have performed the necessary professional services and was present at the construction site on a regular and periodic basis.To the best of my knowledge,information,and belief the work proceeded in accordance with the requirements of 780 CMR and the design documents approved as part of the building permit and that I or my designee: 1. Have reviewed,for conformance to this code and the design concept,shop drawings,samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Have performed the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Have been present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work was performed in a manner consistent with the construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. Enter in the space to the right a"wet"or O AR electronic signature and seal: c+ off Phone number: (617)440-7568 Email:vince(Danaloguestudio.com Building Official Use Only Building Official Name: Permit No.: Date: Version 06 11 2013 . SMITH COLLEGE CUTTER-ZISKIND RENO 79 ELM STREET NORTHAMPTON, MA 01063 PHASE 2 CERTIFICATE OF OCCUPANCY 410-1 � SMITH COLLAGE The Commonwealth of Massachusetts City of Northampton - Certificate of Occupancy In accordance with 780 CMR,Section 111 (The Eighth Edition of the Massachusetts State Building Code) this Certificate of Occupancy is issued to the premise or structure or part thereof as herein identified. Identifi/Name of Building of Space Within Certificate No. Issued for Smith College Cutter-Ziskind House BP-2014-1012 Cutter and Ziskind Residential 1St, 2nd and 3rd Floors Certtif icate Identifij properhj address including street number, name, cihj or town and counttj Expiration icat e Located at 79 Elm Street Northampton, Hampshire, Massachusetts Use Group R-2 (Residential Dormitiory) Use occupancy Classification(s) R-2 200 Including Accessory Uses (Dining Area, Kitchens) A-2 This Certificate of Occupancy is hereby issued by the undersigned to certify that the premise,structure or portion thereof as herein specified has been inspected for general fire and life safety features. This certificate shall posted in a conspicuous place within the space as directed by the undersigned. Failure to post the certificate,failure to conlply with conditions or, tampering with the contents of the certificate is strictly prohibited. Occupancy 1St,2nd and 3rd floors. Conditions of All structural and life safety systems must be maintained. Temporary Use Annual inspections are required. Name of Municipal Charles Miller Date of Map/Plot: Building Official Inspection 08/16/2014 Signature of Municipal Date of 31B-201 Building Official Issuance 08/16/2014 e s s 1014 1 t+; ClTN' C}F N0RT1[.k.N1 E'-l'oN • `: �FrF:�C-1�`Si47'r-In.�.t.11;�� 4GITIl t��,1?i,t�[.tiT'hl+�h4!��'Ela�#:'IClgt�. DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c 142x) BUILDING PERMIT �_I t,I+ P1m1 AlISSION 1.5 fl1��D} (r'R.l;1r''fi"L`I3 T(J: confrucfor.� License: CONSIGLI CONSTRUCTION CO INC 91762 jp nlicant !QQN51QU C OQNSTRUC4"llQ14 CO INC IT,- 71#ELM-nT -7fc hID-ict TTER TO Pf.RFL?RM 1-111; 1 ()LL0fi"f;ti`6 IF ORK.PHASF 2 1-10sT "I III* { 1Ft11 s0 1 T Is \ IS B1.1� FRO,\1 T I I F ST 1.FT 1#ssrir t r z+t F ua� +its In1t rcr.,,r of 1S rt fnp r�.l',1�. ft�,4La Ina rct r 1 �tle��iomttd. ^-",. `�#'r+��'r.• �frter; Rr»rsr� fins► 1 _/ .'t... t g Routh F'rrntr. vie Ass ■■ - � t.m3R` 1Al.�,rT�. fg t'C�f,iS�,{ gW Ort#c`1: TI1Is I'MMIT MAN P1 I(I,A -%-A I'Y (K tit R I II-vNIPTON UPON %1 1-NTION 01- '1 \i 1` O F I I`s R U I I. .k :? It IA ('LA ,� ��< ,� �✓ �t�s ,�fc�#„r �,elf r tip oo ".124t. 4x 1 �,�:�s 14/s:,nfr�;:l.. �I'1� �{•,}tj,;,.,#f41k?.si.# c RECEIVEDr APR ;. N ilon �12 7/1/14 eX 4- AbkJ 7837- d*& rAr�"'�� ot S'y�,e'JJv/s f>ZNNC ��d T �.✓ �*'S o'er' fJle-y r9e-1 1 79 ELM ST-ZISKIND/CUTTER BP-2014-1012 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3 1 B-201 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT Permit# BP-2014-1012 Project# JS-2013-001320 Est. Cost: $9751421.00 Fee: $52397.00 PERMISSION IS HEREBY GRANTED TO. Const. Class: Contractor: License: Use Group: CONSIGLI CONSTRUCTION CO INC 91762 Lot Size sq. ft.): Owner: Smith College Zoning: EU(100)/URC(100)/ Applicant: CONSIGLI CONSTRUCTION CO INC AT: 79 `LM ST -- 2=1SK!ND/QUTTER Applicant Address: Phone: Insurance: 72 SUMMER ST (508) 458-0487 WC MILFORDCT01757 ISSUED ON:41412014 0:00:00 TO PERFORM THE FOLLOWING WORK:PHASE 2 POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground; Service: Meter: Footings: Rough: 7��`�i Rough: House# Foundation: Driveway Final: Final: �i ��/' Final: Q,Sn"A Rough Frame: 'Vo+ C6vr4'V4✓t t Gas: Fire Department Fireplace/Chimney: Rough: Insulation: i 7�//Xx Final:��Y M .,, THIS PERMIT MAY BE REVO ITY OF NORTHAMPTON ZWN:IOLATI N ON OF ANY OF ITS RULES AND U Certificate of Occupancy ��'t'u'O IrZou:�CJly FeeType: Date Paid: Amount: oK. QC Building 4/4/2014 0:00:00 $52397.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner