The URL can be used to link to this page

Home My WebLink AboutInteragency request for inspection INTERAGENCY REQUEST FOR INSPECTION kElURN TO: Division of Licensing MN Dept. of Human Services 444 Lafayette Road TO St. Paul, MN 55155-3842 [ ] State/Local Health Inspector [ [ ] kocal Building Code Inspector State/Local Fire Inspector FROM: ' ens in Consultant Date: license, v g Prior to issuing a is verification is required that a facility is in compliance with appropriate state or local codes for health, building and fire. Please complete the appropriate section and return to the Licensing Division with any orders attached. A copy of orders should be provided to the program. Name of Facility: Pro osed use: Name of PrORrRm: O �'�� one: 3 - 3 3 Address: 3��' /��'� /, �J�-c7n-� y S 3S 6 street ( city zip county Contact Person. �� r Phone: Address: street city zip Area to be used: Numbers and Age Ranges of Participants: Facility plans to Basement [ j 6 wks. to 16 mos. serve handicapped: First [ J 16 mos. to 2 1/2 yrs. Yes [ ] Second [ ] 2 1/2 yrs. to 6 yrs. 60 No ( j Other [ ] specify 6 yrs. to 12 yrs. over 12 yrs. Over 18 yrs. HEALTH REQUEST: ( ] Licensed [ ] Not Licensed [ ] Application left or mailed [ J N/A ( ] No orders necessary at time of inspection [ ] Major orders issued [ ] Minor orders issued [ J Major revisions needed before license can be issued Signature: Date: Comments: Reverse side. BUILDING CODE REQUEST: ( ] Not applicable; facility is located in a non-code area of state . Signature and Title of Local Official 6(_0C, GFS L L. Date: r2-,L- 'I'f An inspection is required for all proposed facilities located in a code area which involved new construction, major renovating or change _tn occupancy i.e. any facility not currently used for the proposed usage. [)Q Facility meats requirements [ J Facility does not meet requirements and cannot be occupied until orders are met. [ J Facility does not meet requirements, but may temporarily be occupied pending completio of orders, until Signature of Building Code Inspector: r4oCertificate Number:Number: IZ�/o Date: t2. - 5y Comments: Reverse side. FIRE CODE REQUEST: w sire inspec�- — requires. 4 ------ Facilities ----Facilities located in an area of the state under the Uniform Building Code must meet the E-3 occupancy requirements of that code in addition to applicable fire code requirements. (If both codes address a specific area, the UBC takes precedence over the fire code.) Facilities located in an area of the state not under the Uniform Building Code must meet applicable fire code requirements. In _either instance, the Minnesota Uniform Fire Code applies. [nJ Facility meets requirements of the fire code. [ ] Facility does not meet requirements of the fire code and cannot be occupied until orders are met. [ J Facility does not meet requirements, but may temporarily be occupied pending completed of orders until Signature of Fire Inspector: 4�1 ?.:� Date: 12 "-2- y Comments: Below. COMMENTS: CONTRACTOR'S MATERIAL&TEST CERTIFICATE FOR ABOVEGROUND PiPING PROCEDURE Upon comom on of work,inspecow and teas snam be made oy the conte Jos repreeerrrattvr and wrMesNd by an ownerseepreserriative,All dehas shall be corrected and ayatam Jett in sarvco before eontrac urs peraonnM finally leave the Job. A eerdf—snw be flow out and signed by both nwesemabves.Copies anau be oreoww tar approving audtorrt s&owners and comracwr it is understood the owners npmsentatives signature in no way prsludices any claim against convacti r for taWty material.poor worKmaronlp,or tadure to comply with approving authontys requirements or focal ordinanoea PROPERTY N&ME PATE � cJv A m s ScAoo /6 PROPERTY ADDRESS 30000 L4,)e>f OACZZ,41,9 SJV01 ORONO ACCEPTED BY APPRCWNG AUTHORITIES(NAMES) ADDRESS PLANS INSiALLATiON CONFORMS TO ACCEPTED PLANS WYES a NO EQUIPMENT USED IS APPROVED 5QYES C NO IF NQ EXPLAIN DEVIATIONS MAS PERSON IN CHARGE OF FiRE EQUIPMENT BEEN INSTRUCTED AS TD LOCATION p9'YES C NO OF CONTROL VALYES AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT IF NQ EXPLAIN INSTRUCTIONS HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES %YES C NO 1.SYSTEM COMPONENTS INSTRUCTIONS -',YES C NO 2 CARE AND MAINTENANCE INSTRUCTIONS t7KYES C NO 3 NFPA13A Z YES C NO LOCATION SUPPLIES BUILDINGS OF SYSTEM MAKE MODEL I MANUFACTURER CTURER ORIFICEAR OF SiZE QUANTITY Iq NG RE 18 SPRINKLERS k r.0 IBRAu rlo 5)sw...,4 Z I _I— C iff A-)-I"A 4 L CeA-)-I"R4L 04ss t4,04 i' AIf-1 PIPE AND TYPE OF PIPE C!i/ /0 FrMNGS TYPE OF FITTINGS V 1-Ic/ Cl_r* ALARM DEVICE MAXIMUM TiME TO OPERATE THROUGH TEST ALARM CONNECTION VALVE TYPE I MAKE ( MODEL I MIN. I SEG OR FLOW INDICATOR v t v S w,c 4 L, P ,e I (A)FD - O 3 Q DRY VALVE O.O.D. MAKE MODEL SERIAL VQ I MAKE MODEL I SERIAL NO. TIME TO TRIP' WATER AlR TRIP POINT TIME WATER ALARM THROUGH TEST PRESSURE PRESSURE AIR PRESSURE REACHED OPERATED CONNECTION I TEST OUTLET' PROPERLY MIN. SEG PSI I PSI PSI MIN. I SEC. YES I NO WITHOUT DRY Pipe O O D OPERATING TEST WITH O.O.D. IF NQ EXPLAIN *MEASURED FROM THE TiME INSPECTOR'S TEST CONNECTION IS OPENED. WA(8.69) PRINTED IN THE U.&A.FOR NATIONAL FIRE SPRINKLER ASSOCIATION,INC,P.O.SOX 1000,PATTERSON,N.Y. 12563 (OVER) aPEAATIUN ❑PNEUMATIC .IzAhf--THIL; URTuevwu%. P1PING SUPERVISED Q YES C N O DETECTING MEDIA SUPERVISED O YES Q NO DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATIONS Q YES Q NO DELUDE A IS THERE AN ACCESSIBLE FAC:UTY IN EACH C:ACUIT FOR TESTING IF NO,EXPLAIN PREACriON VALVES Q YES QNO DOES EACH CIRCUIT OPERATE DOES EACH C:RCUIT MAXIMUM TIME 70 MAKE I MODEL SUPERVISION LOSS ALARM OPERATE VALVE RELEASE OPERATEf YES No Y155 I NO MIN. AELE/�SE HYDROSTATIC.Hydrostatic tests snali be made at not lees then 200 tlsl(136 bars)for two hours or 50 par(3A barsl above static prserim in encase of 150 psi(10.2 bans for two hours Oifferential dry-pipe valor c=pers snag be cert open dunnq test to prevent damage,All aboveground piping TEST leakage snad be swoped. 0E21CRI1111PTION PNEUMATIC:Establisn e,0 psi(2.7 bars)air pressure and measure droo which shad not eeaed 1+A psi(0.1 bars)In 24 hours.Test pressure tanks at normal water,ever and air pressure and measure air pressure droo which snag not each'1'A psi(e,1 bars►in 24 hours. ALL PIPING HYDROSTATICALLY TESTED AT PSI FOR HAS. IF NO,STATE REASON DRY PIPING PNEUMATICALLY TESTED O YES Q NO EQUIPMENT OPERATES PROPERLY O YES CO NO DO YOU CERTIFY AS THE SP91NKLER CONTRACDR THAT ADDITIVES AND CORROSIVE CHEMICALS.SODIUM SILICATE OR DERIVATIVES _Of SODIUM SILICATE BRINE.OR OTHER CORROSIVE CHEMICALS WERE NOT USED FOR TESTING SYSTEMS OR STOPPING LEAKS? 14171 TESTS DRAINI READING OF GAGE LOCATED NEAR WATER SUPPLY TEST PIPE. RESIDUALPAESSURE WITH VALVE IN TEST PIPE OPEN WIDE TEST 1 STATIC PRESSURE PSI PSI Underground mains and lead in connections to system risers flushed before connection made to sprinider piping. VERIFIED BY COPT CF THE U FORM NQ 858 Q YES O NO EXPLAIN FLUSHED 8Y INSTALLER OF UNDER- GROUND SPRINKLER PIPING O YES O NO YI(TE-7NG NUMBER USED I LCC.ZTIONS NUMBER REMOVED %Sr 414 WELDED PIPING YES C NO IF YES... 00 YOU CERTIFY AS THE SPRINKLER CONTRACDR THAT WELDING PROCEDURES COMPLY WITH THE REQUIREMENTS OF AT LEAST AWS 0105.L—=IELAR3 PtYES C NO WELDING DO YOU CERTIFY THAT THE WELDING WAS PERFORMED 13Y WELDERS QUALIFIED IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS 0109.LEVEL AR-3 111t1YES O NO DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN CCMPUANCE WITH A DOCUMENTED QUALITY CONTRCL PROCEDURE i'0 INSURE THAT ALL DISCS ARE RETRIEVED.THAT OPENINGS IN PIPING ARE SMOOTH.THAT SLAG AND OTHER WELDING RESIDUE ARE 9EMCVEM AND THATTHE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED YES C NO CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL (DISKS) CUTOUTS(DISKS)ARE RETRIEVED AYES Q NO HYDRAUUC NAMEPLATE PROVIDED ( IF NQ EXPLAIN NAMEPLATE O YES •O NO GATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN: //1/6 9 REMARICS NAME OF SPRINKLER CONTRACTOR TESTS WITNESSED 9Y SIGN=RE8 FOR P PC. OWNER(SIGNED) DATE I7Vt(C.Qt 0r CX . -16 .5 FORIP6IINKLER CON (SIGNED) ��T3� DATE ADDITIONAL EXPLANATION AND NOTES 85A BACK INTERAGENCY REQUEST FOR INSPECTION RETURN TO: Division of Licensing MN Dept. Human Services Gm16L- _ __ 444 Lafayette Road MAR Q 1 1999 St. Paul, MN 55155 TO: ! �. 6 [ J State/Local Health Inspector �3a�11 Y Ur UKO��Local Building Code Inspector may, [,'1 State/Local Fire Inspector FROM: Licensing Consultant DATE: 2'Z- S 6Si .a yd 6315/ Prior to issuing a license, verification is required that a facility is in compliance with appropriate state or local codes for health, building and fire. Please complete the appropriate section and return to the Licensing Division with any orders attached. A copy of orders should be provided to the program. ��// (11 ``"" Name of Facility: Proposed Use:L/ZCl�� `! 6JZ y7S��z� Name of Program: Phone: 4a� Address:�� City Zip Area to be used: Numbers and Age Ranges of Participants: Facility Plans to Basement [ 6 wks. to 16 mos. serve handicapped: First 16 mos. to 2 1/2 yrs. Yes [ ] Second [ ] 2 1/2 yrs. to 6 yrs. _ / No ( ] Other [ ] 6 yrs. to 12 yrs. )s Specify: over 12 yrs. HEALTH REQUEST: ( ] Licensed ( ] Not Licensed [ ] Application left or mailed ( J No orders necessary at time of inspection ( J Major orders issued [ J Minor orders issued [ J Major revisions needed before license can be issued Signature: Date: Comments: Reverse side BUILDING CODE REQUEST: [ ] Not applicable: facility located in non-coded area of state Date of referendum vote removing code requirements: Signature and Title of Local Official:QzluA( Date: ' An inspection is required for all proposed fac ities located in a code area which involves new construction, major renovating or change in occupancy i.e. any facility not currently used for the proposed usage. �Pq Facility meets requirements [ ] Facility does not meet requirements and cannot be occupied until orders are met. [ ] Facility does not meet requirements, but may temporarily be occupied pending completion of orders until Signature of Building Code Inspector: Certificate Number: Date: Comments: Reverse side FIRE CODE REQUEST: A fire inspectiom is required for all proposed facilities. Facilities located in an area of the state under the Uniform Building Code must meet applicable fire code requirements. (If both codes address a specific area, the UBC takes precedence over the fire code. ) Facilities located in an area of the state not under the Uniform Building Code must meet applicable fire code requirements. In either instance, the Minnesota Uniform Fire Code applies. �A_Facility meets requirements of the fire code ( j Facility does not meet requirements of the fire code and cannot be occupied until orders are met ( j Facility does not meet requirements, but may temporarily be occupied pending completion of orders until Signature of Fire Inspector: Date: 2 31'9 Comments: Below Comments: