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- _ __ _ 301 York Ave <br /> St.Paul,Minnesota 55130 <br /> V� �� N� (651)558-3300 • (800)229-6263 <br /> AU1�1ATIt SPWNKLER CO. Fax: (651)558-3310 <br /> AGREEMENT AND REPORT OF INSPECTION <br /> SHFFT 1 ul 2-Use separnte sheet for each building inspected #INSPECTiON �� ��� ��' �� <br /> MINNESOTA LICENSE NO.C005 <br /> REPORT TO = ;,,,, � ,J �, f�.' ,: BUILDING OR LOCATION < ,;^y-�� , <br /> STREET � i%.. ,'i ��'� t ��� ,. 4_? INSPECTOR ;`�r�.�-t � r= �, ,� �'�'" <br /> CITY&S`I'ATE `'±.�i �_�. j�, DATE � - �� <br /> Customer hires Viking Automatic Sprinkler Company to conduct an inspection of the fire suppression system�t the above location or building,and <br /> prepare a written report of that inspeckion for an agreed upon fee. As p�rt of this agreement,customer agrees to terms and conditions on rear of forin <br /> and will complete the Owner's Section of this docunlent Viking Automatic Sprinkler Company will not be held liable for incorrect or w�kown <br /> answers provided in the Owner's Section. <br /> Owner's Section(To be answered by Owner,Occupant or Customer) <br /> A. Explain any occupancy hazard chan�es since the previous inspection: � ,��-,,� <br /> B. Describe fire protection modifications made since last inspection: f ; <br /> C. Describe any fires since last inspection: d t u; :• <br /> �a <br /> D. When was the systein piping l�st checked for stoppage,corrosion or foreign material? �, ,�, � ,, �_; „ <br /> E. When was the dry-piping system last checked for proper pitch? <br /> F. Are dry valves adequately protected kom keezing? � "�� <br /> G. Does the system contain any low point drain� r�Yes o No lf yes,please state how ma�v�nd the gcneral location oE each: �- (��{i �i 4(p S <br /> , . . , . <br /> .�—�L+—,�R � �.�- ���' -�i; =�' t w t' . �r � t l.,j . .1 eT_{,. � t� _��-- ��.X:� <br /> Signaturc ��; I'iHc Uatc ;!' �/ ' <br /> Inspector's Section(All responses reference current inspection) N/A=NOT APPLICABLE <br /> 1 General <br /> a. Is the building occupied? i�'es ��No <br /> b. Are all systems in service? �Yes ❑No <br /> c Docs thcre appear to be a minimum of 18 in.(457 mm)dcarance between the top of the storage and the sprinkler deflectors? i�Yes ❑No <br /> d. Does the valve hose on the sprinkler system(s)appear to be satisfactory? ri Yes ❑No �N�A <br /> 2 Control Valves(See Item 15) <br /> a. Do sprinkler system contro]valves appear to be in the appropriate open or closed position? {�Yes u No <br /> b. Are control valves in the open posikion locked,sealed or equipped with a tamper switch? �-Yes i�i No <br /> 3 Water Supplies(See Iten�16) � � <br /> a. Was a water flow test of main drain made at the sprinkler riser(s)? r�es �:No <br /> 4 'I'anks,Pumps,Fim Department Connections <br /> a. Are fire pumps,gravity tanks,reservoirs and pressure tanks in good condition and properl��maintaineci? ❑Yes n No �''N�A <br /> b. Are fire department connections in satisf�ctoiy condition,couplin};s free,caps in place,and check valves tight? �1'es n No ❑N/A <br /> Are they accessible and visible?�Yes �-No ❑N�A <br /> 5 Wet Svstems <br /> a. Are cold wcather valves(O.S.&Y.)in the appropriate open or closed position? ❑Yes i_�No �N/A <br /> b. Have antifreeze system solutions been tested? ❑Yes �No �A <br /> c Wem the antifreeze test results satisf�ctory? ❑Yes ❑No �A <br /> d. In areas protected by wet system(s),does the building appear to be properly heated in all areas,including blind attics and perimeter areas <br /> where accessible? u Yes c No :�j(N�A Do all exterior openinys appear to be protected against freezing? ❑Yes u No �T�A <br /> 6 Dry System(See 1 tents 11 to 13) � <br /> a. Are dry valves(s)in service? I�tS'es c No ❑N�A <br /> b. Are the nir pressures and pri�nin�water levels in accordance with the manufacture's instructions? �Yes ❑No ❑N/A <br /> c I Ias the operation of the air or nitrogen supplies been tested? y�4 es ❑No ❑N/A Are they in service?�Yes ❑No ❑N/A <br /> d. Were all know low points drained during this inspection? �s ❑No u N/A <br /> e. Did quick-opening devices eperate satisfactorily? �'es u No ❑N�A <br /> f. Did thc dr��valve(s)trip properly during the trip pressure test? �Yes ❑No r i N/A <br /> g. Did the heating equipment in the dry-pipe valve room(s)operate at time of inspection? �Yes ❑No ❑N�A <br /> 7 Special Systems(See Iterri 14) <br /> a. Did thc dcluge or pre-action valves operate properly during testing? u Yes ❑No pCN/A <br /> b. Did thc heat-responsive devices operate properly during testing? ❑Yes ❑No ��A <br /> c Did supervisory devices operate during testing? �i Yes ❑No �IV/A <br /> 8 Alarms <br /> a. Did water motor(s)and gon�(s)test satisf�ctorily? n Yes ❑No �fV�A <br /> b. Did elecri-ic alarm(s)test s�tisfactory? �Yes u No �N�A <br /> c. Did supervisory alarm service test satisfactory? �CYes a No ❑N/A <br /> 9 Sprinklers <br /> a. Do visible sprinklers�ppear to be free from corrosion,loading or obstruction to spray disch�rge?�QCYes �No <br /> b. Are sprinklers less than 50 years old? (Older sprinklers require sample tes6ng)�es i-i No <br /> c Are quick response and residential sprinklers less than 20 years old? (Older spxinklers reyuire sample testing) u Yes c No �I/A <br /> d. Is stock of spare sprinklcrs available? �5`es n No <br /> e. Does the exterior eonc�ition of sprinkler systein appear to be satisfactory? �CYes o No <br /> f. Do visible sprinklers appcar to be of proper temperature rating for their locations? �,Yes ❑No <br /> 10 Explain any"No"answers and comments: <br /> . � � �� —� <br /> Signature: �ti,�y,�/ Datc: ' <br /> (Re��-9/0'_/119) <br />