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EXCELS/OR F/14E D/STRICT — F/RE COOE �'c SAFETY /NSPECT/OI�fS
24 100 SM/THTOWN ROAO SHOREWOOp M/NNESOTA 5533 1
1NSPECTOR Z KELL/E MUl7PHY-R/NGATE 952.96Q. 7692/nnurphynngate�PXCfIJ7o7F�(rC,olB
/NSP£CTOR 3 LEE BERGLUNO 952.960.7693 /be �undLa7esce/iiorfii�.or
�CCLJPANCY: DATE:
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ADORESS: EMER ENCY
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PHONE: �. \ / � p,rj�}. •.f�I-�?=��r EMERGENCY / \
7�T' / �( C%C.- 7'� C�li(.%'ti'-C4� C7/'F(Li PHONE #: E.� l�� � � .. 7 ��T�
Inspection of the occupancy listed above been DEEPHAVEN COMMENTS:
completed in accordance with the 2000 IFC and EXCELSIOR /�`',-V':tiJ� S � ��f�'�J�f�,�'.
the MSFC adopted by the ciry of:»»»» GREENWOOD � �- � � �
The followi�g violations and/or deficiencie HOREWOOD � , � `�" ' y �-� • � /��,
r uiring corrective action are noted below. ��`�`�fJ`� ONKA BAY � �'/l '
:-1--� "
EXTERIOR: # FIRE PROTEC ION SYSTEMS: .#
Address visible and legible-Front and rear doors 1 Sprinkler heads in good condition-proper coverage 21
Fire hydrants accessible-36" minimum clearance 2 Door to sprinkler system control room marked 22
Fire lanes-Fire Department access 3 Riser & control valves accessible/current inspection 23
FDC unobstructed &visible-proper caps-3' clear 4 Control valves locked open or tamper protected 24
Horn/strobe operational -unobstructed &visible 5 Extinguishers properly located-current inspection 25
Knox Box with properly labeled ke s B Commercial hood systems-clean & inspected 26 �
Dumpsters minimum 5' from building � Class K extinguisher present in commercial kitchen 2? °
Gas meters & piping protected 8 Fire alarm system in good condition-inspected 28
Buildin exterior maintained 9 Door to fire alarm room identified 29
EXITS: # INTERIOR/STORAGE: #
Exit doors unobstructed, operable, proper hardware 10 Sfiorage 18" or more below sprinkler heads 30
Exit corridors maintained and unobstructed 11 Storage 24" or more below unprotected ceilings 31
Exit signs illuminated 12 No storage in unprotected attics or below stairs 32
Proper exit signs displayed-6" minimum letters 13 No storage in mechanical or electrical panel rooms 33
Emergency lighting in good operating condition 14 No storage in boiler or elevator equipment rooms 34
Occupancy load posted (assembly) 15 Trash & oiiy rags properly kept or removed daily 35
ELECTRICAL EQUIPMENT: # Flammable and combustible liquids properly stored 36
Door to electrical room/ panel labeled 16 Hazardous materials properly stored and identified 37
30" clear access to electrical panels 17 Compressed gas cylinders properly secured 38
Open spaces in electrical panels-knockout plugs 18 Ceiling tiles in place &undamaged 3g
Electrical hazards- power strips/circuit protected 19 Wall or ceiling damage repaired/seal penetrations 40
No extension cords used as permanent wiring 20 Smoke detectors operational/proper location 41
Code V,iolation Summary: �; f,`;�;7-,�L� � „ ,�-r;�);��_.��, � '`.�.� �.;� .� ,�
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�'V�� �' � `����—TL'�� %%�"�%� /%s�'(�,!L��.�'.� �C_(', /iy The Fire District reserves the right to enforce Ithe
" MSFC if any other violations are di::covered during
� the compliance process or as they may arise.
� � _� � Signature indicates receipt of copy
X U'i� �_��'�� � ��� �T�'�� and cooperation with compliance
Owner of Representative � celsio ' istrict�lnspector orders within �('� days.
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WAYZATA I
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SUMMIT FIRE PROTECTION
575 MINNEHAHAAVE.W•ST.PAUL,MN 55103•(651)251-1880 3026 40TH AVE.IVW•ROCHESTER,MN 55901 •(507)280-0622
'418 GR�AT OAK DR.,WAITE PARK,MN 56387•(320)257-6390 760 LIBERTY WAY,NORTH LIBERTY,IA 52317•(319)665-4330
4208 ENTERPRISE CIRCLE•DULUTH,MN 55811 •(218)740-4412
SHEET 1 OF 2-Use sepazate sheet for each building inspection REP�RT�F''I1�SPECTI�lv
MINNESOTA LICENSE NO. C0075 JOB NUMBER
�' INSPECTION NAME BUILDING/LOCATION
STREET INSPECTOR
CITY&STATE DATE
Owner's Section(to be answered by Owner or Occupant)
A. Explain any occupancy hazard changes since the previous inspection:
B. Describe fire protection modifications made since last inspection:
C. Describe any fires since last inspection:
D. When was the system piping]ast checked for stoppage,corrosion of foreign inaterial?
E. When was the dry-piping system last checked for proper pitch?
E Are dry valves adequately protected from freezing?
Signature Title � Date
Inspector's Section(All responses reference current inspection) NA=NOT APPLICABLE
1. General
a.Is the building occupied?DYes ❑No
b.Are all systems in service? DYes❑No
c.Is there a minimum of 18 in.(457 mm)clearance between the top of the storage and the sprinkler deflectors? OYes ❑No
d.Does all electrical heat tape appear to be satisfactory? ❑Yes ❑No 0�NA
e.Does the hand hose or standpipe on the sprinkler system(s)appear to be satisfactory? ❑Yes ❑No O NA
2. Control Valves(See Item I5.) �
a.Are all sprinkler system control valves and all other valves in the appropriate open or closed position? ❑Yes ❑No
�' b.Are all control valves in the open position locked,sealed or equipped with a tamper switch? OYes 0 No
3. Tanks,Pumps,Fire Department Connections
a.When was fire pump last tested for performance?
b.Are fire pumps,gravity tanks,reservoirs and pressure tanks in good condition and properly maintained? ❑Yes❑No ❑NA
c.Are fire department connections in satisfactory condition,couplings free,caps in place,and check valves tight? DYes ❑No ❑NA
Are they accessible and visible? OYes 0 No ❑ NA
4. Wet Systems �
a.Are cold weather valves(O.S.&Y.)in the appropriate open or closed position? ❑Yes ❑No O'�NA
b.Have antifreeze system solutions been tested? ❑Yes ❑No ❑NA �
c.What temp is antifreeze? �
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
where accessible?❑Yes ❑No O�NA
5. Dry System(See Items l] to 13) ,�
a.Are dry valve(s)in service? ❑Yes ❑No ❑NA
b.Are the air pressures and priming water levels in accordance with the manufacturer's instructions? ❑Yes ❑No 0 NA �
c.Has the operation of the air or nitrogen supplies been tested? OYes❑No ❑NA Are they in servicc? ❑Yes❑No ❑NA �
d.Were low points drained during this inspection?OYes ❑No❑NA How many?
e.Did quick-opening devices operate satisfactorily? ❑Yes ❑No C}NA
f.Did the dry valve(s)trip properly during the trip pressure test? DYes ❑No❑NA
g.Did the heating equipment in the dry-pipe valve room(s)operate at time of inspection? DYes ❑No ❑NA
6. Special Systems(See ltem 14.) �
a.Did the deluge or pre-action valves operate properly during testing? ❑Yes ❑No ❑NA �
b.Did the heat-responsive devices operate properly during testing? ❑Yes ❑No❑NA
c.Did supervisory devices operate during tes[ing? ❑Yes❑No ❑NA
d.Did flow for kitchen hood system shut off gas or electric? ❑Yes 0 No ❑NA
7. Alarms
a.Did water motor(s)and gong(s)test satisfactorily? ❑Yes 0 No ❑NA
b.Did electric alarm(s)test sarisfactorily? DYes❑No ❑NA
c.Did supervisory alarm service test satisfactorily? ❑Yes ❑No ❑NA
d.Did tamper switches test satisfactorily? ❑Yes ❑No 0 NA �� �
8. Sprinklers
a.Are all sprinklers free from corrosion,loading or obstruction to spray discharge? OYes ❑No
b.Are sprinklers less than 50 years old?(Older sprinklers require sample testing) ❑Yes ❑No
c.Are quick response and residential sprinklers less than 20 years old?(Older sprinklers require sample testing) ❑Yes ❑No �
d.Is stock of spare sprinklers available? DYes ❑No
e.Does the exterior condition of sprinkler system appear to be satisfactory? OYes❑No
f.Are sprinklers of proper temperature rating for their locations? ❑Yes ❑No
g.Are any sprinkler heads{on a recall list?❑Yes ❑No
Signature: . Date:
�
SUMMIT FIRE PROTECTION
575 MINNEHAHAAVE.W•ST.PAUL,MN 55103•(651)251-1880 3026 40TH AVE.NW•ROCHESTER,MN 55901 •(507)280-0622
4�GREOT OAK DR.,WAITE PARK,MN 56387•(320)257-6390 760 LIBERTY WAY,NORTH LIBERTY,IA 52317•(319)665-4330
4208 ENTERPRISE CIRCLE•DULUTH,MN 55811 •(218)740-4412
SHEET 2 OF 2-Use separate sheet for eachsystem inspection Type of System '
Inspection Name and Number How Many? �����
What Size?
Flow Switch or
Alarm Check with Pressure Switch
9. Date dry-pipe valve trip tested (control valve partially open) (See Trip Test Table which follows)
10. Date dry-pipe valve trip tested (control va(ve fully open) (See Trip Test Table whicn follows)
11. Date quick-opening device tested (See Trip Test Table which follows)
DRY VALVE TRIP TEST TABLE o.o.�.
MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO.
DRY PIPE Time to Trip Water Air Trip Point Time Water Reached Alarm Operated
OPERATING Thru Test Pipe Pressure pressure Air Pressure Test Outlet Properly
TEST MIN. SEC. PSI PSI PSI MfN. SEC. YES NO
Without . �- '
Q.O.D. J
With
Q.O.D.
12. Date deluge or preaction valve tested (See T'rip Test Table which fo/lows)
TRIP TEST TABLE
Operation ❑ PNEUMATIC ❑ ELECTRIC � HYDRAULIC
Piping Supervised ❑ YES ❑ NO Detecting media supervised ❑ VES ❑ NO
DELUGE& Does valve operate from the manual trip and/or remote control stations ❑ YES ❑ NO
PREACTION Is there an accessible facility in each circuit for testing Method ot testing-circuits
VALVES ❑ YES ❑ NO
Does each circuit operate Does each circuit Maximum time to
MAKE MODEL su rvision loss alarm o erate valve release o erate release
YES NO YES NO YES NO
13. See Control Valve Maintenance Table.
Control Va1ve Maintenance Table
Explain
Abnormai
Control Vaives Number Type OQen Secured Closed Signs Condition
City Connection Control — �
Valve , _.._
Tank Control Vaives
Pump Conhol Valves
Sectionai Control Valves
System Control Valves f -
Other Control Valves
Kitchen Control Valve
16. Water Flow Test at Sprinkler Riser
Water Supply Source: City , Tank Pump
Date Test Pipe Size of Static Residual Differential
Location Test Pipe Pressure (Flow)
Pressure
��'�----�ast�Water Flow Test
This WaCer Flow Test �
14. Explain any"No"answers and comments:
�f�
Signature: I Date:
�^-,v~� ''�"k�--T''-ri�'T+--�j`
d
,�i
SUMMIT FIRE PROTECTION
��� 575 Minnehaha Ave.W. • St.Paul,MN SS l 03 • 651-251-1880 3026 40th Ave. N W • Rochester,MN 55901 • 507-280-0622
�� 418 Great Oak Dr. • Waite Park,MN 56387 • 320-257-6390 760 Liberty Way • North Liberry, [A 52317 • 319-665-4330
� 4208 Enterprise Circle • Duluth,MN 5581 I • 218-740-4412 4353 NW Urbandale Dc • Urbandale,IA 50322 • 515-867-2424
r
'y SHEET 2 OF 2-U -separ te sJteet for e �, ystem inspection Type of System �
'';
��� Inspection Name -F"`�. G t� '� ��(Y7�;� �'; � �„- +'�� � How Many? _� /�
��'' A
'... Inspection Work Order f "'� � What Size? �
Flow Switch or Alarm Check with Pressw��Swirch �
9. Date dry-pipe valve trip tested(control valve partially open) � ����� (see Trip Test Table which tollows)
10. Date dry-pipe valve trip tested(control valve fully open) _ (see Trip Test Table which follows)
ll. Date quick-opening device tested � (see Trip Test Table which follows)
DRY VALVE TRIP TEST TABLE Q.O.D.
AKE MODEL SERIAL NO. MAKE MODEL SERIAL NO.
� G.a ,e
l._'
DRY PIPE Time ro Trip Trip Point Time Water Reached Alarm Operated
OPERATING Thru Test Pipe �'�'ater Pressure Air Pressure Air Prestiure Test Outlet Propedy
- TEST Min. Sec. �� PSI � PS[ - � PSI � Mia Sec. Yes� No
Without
O.D. �
With
Q.O.D.
12. Date deluge or preaction valve tested (see Trip Test Table which follows)
TRIP TEST TABLE
Operation ❑Pneumatic ❑Electric ❑Hydraulic
Piping Supervised ❑Yes ❑No Detecting Media Supervised ❑Yes ❑No
DELUGE& Does valve operate from the manual trip and/or rcmote control stations'? ❑Yes ❑No
PREACTION
VALVES Is there an accessible facility in each circuit for testing'? ❑Yes ❑No Method of Testing Circuits:
MAKE MODEL Does Each Circuit Operate Does Each Circuit Maximum Time to
R"s Supervision Loss Alarm? Operate Valve Release? Operate Release?
❑Yes ❑No ❑Yes ❑No ❑Ye.c ❑No
13. See Contro]valve Maintenance Table CONTROL VALVE MAINTENANCE TABLE
CONTROL VALVES NUMBER SIZE&TYPE OPEN SECURED CLOSED SIGNS EXPLAIN ABNORMAL CONDITIONS
City Connection Con[rol Valve .— L� �� � � ✓� ���
Jockey Control Valve
' Pwnp ConVol Valves
Additional Pump Control Valves
Test Header
Sectional Co�trol Valves
Sys[em Control Valves �'�� � v ��`� �F� �`� � ��
-�.�
Other Control Valves
Kitchen Contro]Valves
Water Flow Test at Sprinkler Riser
;, Wa[er Supply Source: City Weli 1'ank Pump
DATE TE5T PIPE I.00ATION SIZE OF TF,ST PIPE STATIC PRF.SSURF. RESIDUAL(FI.Ow) pIFFERENTIAL
PRETES'f POSTTF,ST PRESSURE
�.-f .. - .-„--�
Las[Wa[er Flow Test t"� �� i', y� r, ��{ iti • � , ..
This Waler Flow Tcst _,./ a �� � � � �� � � �
" � � , . , j � " . , :�f, r�o f f�
� 14. Explain any"No"answers and comments: � �'`�� x � '�"i�4 ' � ° �� � �'1 ��Gi�t k-fi'�Y�
, , �� . . � . �`, 3 ' . i� (: . ,.� . .. �.,�'.
�(,(�'c"( C �/�/ ��if"';' j �";`�'. �C (�.t"' �-�,, -f � � �'ba � �
f�f 4!r n c .
�
; ;
Print Name � � `���� ��� Signature f � � �"n� Date - � � ��
�
SUMMIT FIRE PROTECTION
575 Minnehaha Ave.W • St. Paul,MN 55103 • 651-251-1880 3026 40T"Ave.NW • Rochester,MN 55901 • 507-280-0622
418 Great Oak Dr. • Waite Park,MN 56387 • 320-257-6390 760 Liberty Way • North Liberty,IA 52317 • 319-665-4330
4208 Enterprise Circle • Duluth,MN 55811 • 218-740-4412 4353 NW Urbandale Dr. • Urbandale,IA 50322 • 515-867-2424
SHEET t OF 2-Use separate sheet for each building inspection REPORT OF INSPECTION ,. _
. ;;.,,, -
MINNESOTA LICENSE NO.C0075/IOWA LICENSE NO. FP-036 JOB NUMBER � `� —
INSPECTION NAME :.-- �; �u{ � BUILDING/LOCATION
STREET :�— ��l:r '� P-..,%<, �, . •,:�:_� � `�. INSPECTOR � ;1;�„; ,�J�j�G.�
CITY&STATE ' :' -`r� � * -- :f' DATE %�� > t j;i
� . - _
Owner's Section(to be answered by Owner or Occ�pant)
A. Explain any occupancy hazard changes since the previous inspection:
B. Describe fire protection modifications made since last inspection:
C. Describe any fires since last inspection:
� D. When was the system piping last checked for stoppage,corrosion of fareign material?
E. When was the dry-piping system last checked for proper pitch?
F. Are dry valves adequately protected from freezing?
Signature Title Date
Inspector's Section(All responses reference current inspection) NA=NOT APPLICABLE
1. General
a.Is the building occupied?��Yes ❑No
b.Are all systems in service? �1'es 0 No
a Is there a minimum of 18 in.(457 mm)clearance between the top of the storage and the sprinkler de�flectors? �1'es ❑No
d.Does the hand hose or standpipe on the sprinkler system(s)appear to be satisfactory? ❑Yes ❑No�NA
2. Control Valves(See ltem I5.) r...,��
a.Are all sprinkler system control valves and a11 other valves in the appropriate open or closed osition? �i-Yes ❑No
b.Are all control valves in the open position locked,sealed or equipped with a tamper switch?�Yes❑No
3. Tanks,Pumps,Fire Department Connections �S
a.When was fire pump last tested for performance? ��Y
b.Are fire pumps,gravity tanks,reservoirs and pressure tanks in good condition and properly maintained? ❑Yes 0�10�NA
c.Are fire department connections in satisfactory condition,couplings free,caps in place,and check valves tight? 67`Xes ❑No ❑NA
Are they accessible and visible?'�Yes❑No ❑NA
4. Wet Systems p
a. Have antifreeze system solu�ions�en tested? ❑Yes ❑No C�1"NA
b.What temp is antifreeze? '✓,t
� � c. In areas protected by wet system(s),does the building appear to be properly heated in all areas? ❑Yes ❑No�1A
5. Dry System(See Items 11 to 13�
a.Are dry valve(s)in service? Yes ❑No ❑NA
b.Are the air pressures and priming water levels in accordance with the manufacturer's instructions? l�'es No❑NA
c.Has the operation of the air or nitrogen supplies been tested? �es 0 No ❑NA Are tt�ey in service? �'es 0 No ❑NA
d.Were low points drained during this inspection?�Yes ❑No NA How many? p`
e.Did quick-opening devices operate satisfactorily? �Yes ❑No J�NA
� f.Did the dry valve(s)trip properly during the trip pressure test?�Yes ❑No 0 NA
�I g.Did the heating equipment in the dry-pipe valve room(s)operate at time of inspection?,�'es ❑No ❑NA
6. Special Systems(See Item 14.)
a.Did the deluge or pre-action vaLves operate properly during testing? ❑Yes 0 No ❑NA
b.Did the heat-responsive devices operate�pkroper}y during testing? ❑Yes ❑No ONA
c.Did supervisory devices operate during,testing? �Yes❑ No ❑NA
d.Did flow for kitchen hood systetri shut off g�"s or electric? ❑Yes 0 No ❑NA
7. Alarms
a.Did water motor(s)and gong(s)test satisfa�torily? ❑Yes ❑No C�NA
,
b.Did electric alarm(s)test satisfactorily? �Yes 0 Ng ❑NA *' f f;,,; a�y,:",•. f
c.Did supervisory alarm service test satisfactorily? G1�Yes ❑No a�IA �;',,;, .� . r •� °�-� ' -�'='
d.Did tamper switches test satisfactorily? �Yes ❑No❑NA ��� ��'' ���; `� ` � � � �
8. Sprinklers
a.Are all sprinklers free from corrosion,paint,loading or obstruction to spray discharge? �Yes ❑No
b.Are sprinklers less than 50 years old?(Older sprinklers require sample testing) CfYes ❑No
c.Are quick response and residential sprinklers less than 20 years old?(Older sprinklers require sample testing) �Yes ❑No ❑NA
d.Is stock of spare sprinklers available? ❑Yes �No
e.Does the exterior condition of sprinkler system appear to be satisfactory? �lYes❑No
f.Are sprinklers of proper temperature,�ating for their locations? �IYes❑No
g.Is location free of recalled heads? �Yes ❑No
�
. ' �
�
�
Signature: � � _ Date: ���� �� �
�