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�� 1301 L'Orient Street I �� (t.j ul,Minneso(a 5)117 I 657 558-3300 • 800 229-6263 AUTOMA'ftC SPRINKLER CO. Fax: (651)558-3310 Set#in� "I'hp Standard... i , *►. AGREEMENT AND REPORT OF INSPECTION SHEF.T 1 of 2-U!�se}��rate sheet for each building inspected #INSPECTION MINNESOTA LICENSE NO.C005 REPORT TO BUILDING OR LOCATION STREET INSPECTOR � CITY&STATE DAT'E - Owner hires Viking Automatic Sprinl:ler Company to conduct an inspection of the fire suppression system at the above locafion or Uuilding,and prepare a written report of that iiispec6on for an agreed upon fee. As part of this agreement,owner agrees to ternis and condidons on r�ar of forni and will complete the Owner's Section of this document. Owner's Section(To be answered by Owner or Occupant) A. Explain any occupancy hazard changes since the previous inspection: _ B. Describe fire protecfion modifications made since last inspection: G Describe any fires since last inspecfion: ` ' " D. When was the system piping last checked for stoppage,corrosion or foreign material? - E. When was the dry-piping systein last checked for proper pitcil? I F. Are dry valves adequately protected from freezin�? SiKnature Title Date I Inspector's Section(All responses reference cunent inspection) N/A=NOT APPLICABLE 1 General I a. Ls the building occupied? �Yes ❑No b. Are all systems in service? �Yes ❑No c. Does there appear to be a minimum of 18 in.(457 mm)clearance between the top of the storaQe and the sprinkler deflectors? r��"es ❑No d. Does the valve hose on the sprinkler system(s)appear to be satisfactory? i�Yes n No +�N/A 2 Control Valves(See Item 15) i a. Do sprinkler system control valves appear to be in the appmpriate open ar closed position? �`Yes ❑No b. Are control valves in the open position locked,sealed or equipped with a tamper switch?__p�'Yes ❑No 3 Water Supplies(See 1 tent 16) ' a. Was a water flow test of main drain made at the sprinkler riser(s)? u'Yes ❑No 4 Tanks,Pumps,Fire Department Coiuiections a. Are fire pumps,gravity tanks,reservoirs and pressure tanks in good condifion and properly maintained? n Yes ❑No d�N/A b. Are fire deparhnent connecHons in satisfactory condition,couplings free,caps in place,and check valves tight? rrYes ��No ��N/A Are they accessible and visible? o Yes ❑No ❑N/A 5 Wet Systems a. Are cold weather valves(O.S.&Y.)in the appropriate open or closed position? ❑Yes ❑No ❑N/A I b. Have antifree•r.e system soluHons been tested? ;.Yes ❑No r�N/A c. Were the antifreeze test results satisfactory? ❑Yes ❑No �N/A d. In areas protxted ry wet system(s),does the building appear to be properly heated in all areas,u�cludin�blind attics and perimleter areas where accessible? n Yes u No r�N/A Do all exterior openings appear to Ue protected against freezin�? o Yes ❑No ❑N/A 6 Dry System(See Itenu 11 to 13) a. Are dry valves(s)in service? ,Yes ❑No 6 N/A b. Are the air pressures and priming water levels in accordance with the manufacture's instrucHons? ❑Yes ❑No ,2i N/A c. Has the operafion of the air or nitrogen supplies been tested? ❑Yes ❑No i��N/A Are tliey in service? ❑Yes ❑No �N/A d. Were all lmow low points drained during this inspection? ❑Yes ❑No n N/A e. Did quick-opening devices operate satisfactorily? ❑Yes ❑No �c5 N/A f. Did the dry valve(s)trip properly during the trip pressure test? ❑Yes ❑No a N/A �. Did the hearin�equipment in fl�e dry-pipe valve room(s)operate at time of inspection? n Yes ❑No :F}N/A 7 Special Systems(See Item 14) a. Did the deluge or pre-action valves operate properly during testing? ❑Yes u No �N/A b. Did the heat-responsive devices operate properly durin�testing? ❑Yes ❑No 'o N/A c. Did supervisory devices operate during testing? ❑Yes ❑No a N/A 8 Alarms a. Did water motor(s)and�ong(s)test satisfactorily? ❑Yes u No �j5 N/A b. Did electric alarm(s)test satisfactory?.o Yes ❑No ❑N/A c. Did supervisory alarm service test satisfactory?:L5 Yes ❑No ❑N/A 9 Sprinklers a. Do visible sprinklers appear to be free from corrosion,loading or obstrucrion to spray dischar�e? ❑Yes ��No b. Are sprinklers less than 50 years old? (Older sprinklers reyuire santple testing) ,��Yes ❑No c. Are quick response and residential sprinklers less thaz120 years old? (Older spruilders require sample testin�) ri Yes n No �i N/A d. Is stock of spare sprinklers available? [�"Yes ❑No e. Does the exterior condition of sprinkler system appear to be satisfactory? p Yes ❑No f. Do visible sprinklers appear to be of proper temperature rating for their locaHons? r�Yes ��No 10 Explain any"No"answers and comments: _ Signature: Date: ' (Rev.�/8/�) , -