The URL can be used to link to this page

Home My WebLink Aboutsprinkler info � � �) :\ �// \\ � O � �_ AUTOMATIC SPRINKLER CO. �� =� ` 1612 94th Lane N.E. • Blaine, Minnesota 55434 • (612) 784-8902 DRY PIPE VALVE TRIP 7EST REPORT FOR ��" - O �� /I _ INSFEGTION �10.�_./ ._.�__._,4.� STREET CITY��`"��,�_� STATE � ' CONTRAGT NO. �- DATE OF TRIP TEST / � � � ` �`� INSPECTOR J DAY WpRK NO. _ _ .._�� STANDAt2D FARM OF TNE NATIONAL AUTOMA IC SPRIN LER AND FIRE CON7ROL ASSOCIA7iAN NOTE: BEF6RE ANY DRY PIPE VALVE IS TRIP TESTED, THE WATER SUPPLY LINE TC IT' SH�u�D eE THOROUGHIY FLUSHE�. THE TWO INCH DRAIN BELOW THE VAIVE SNOULD BE OPENED WIDE, AND WATER AT FULL PRESSURE SHOUI.D 8E DISCHARGED L03�lG ENOUGH TO CLEAR THE PIPE OF ANY ACCUMULATION OF SCAI.E OR FOREIGN MA?ERIAL. IF THERE IS A HYDRAMT ON THE SUPPLY LINE, TNIS HYDRANT SHOULD BE FLUSHED BEFORE THE TWO INCH DRAiN IS OPENED. THE DP.IP VA�VE ON THE DRa PIPE VALVE SNOULDBE CHECKED BEFORE TRIPPING THE DRY PIPE VALVE, TO SEE TMAT IT 15 !N OPERATING CONpITION. DRY PIPE VALVES SYSTEM NO. ( ) SYSTEM NO. ( ) SYSTEM NO. ( ) SYSTEAA NO. ( } VALVE SFRIAL NUMBER MANUFACTURER INAMEI _ /�r/ � __ _ -_-�- VALVE MODEL_ � � � _ � �`� _` VALVE SIZE INCH INCN INCH INCH _- __-______._..-.�_-. —_..__ ___ '—__'�.�_ _.'_�-__.�.-'-� (LOCATIONI -,��--, � CONTROLLING SPRINKLER5 /� - --��-�-` ��- -'�--- '�- '—'�'- I (NUMBER) /[� IAPPROX) IAPPROXI (APPqOX) (APPROX) -,�� - DATE LAST TRIP TESTEDt ,�►-- � DATE LAST OPERATED? � -_�-� �� AIR� ---- - _�� LB5 V L5� A 1.85 � LBS PRESSURE BEFORE TEST � � -'-� �'" - --�WATER L.Bs I �.Bs I �e� LBs --- --��--- -t- ----a---- - SIZE AND LOCATION OF TEST VALVE e�/ (y� I _ WAS GATE VALVE BELOW DRY VALVE OPEN J�i } /� —� WIDE AT TEST? (IF NOTx HOW MANY TURNS?) IJV /I,�L __ � __..___ AIR PRESSURE � �BS �es �e5 LBS VALVE TRIPPED AT WATER PRESSURE LBS �Bs LBs �BS � TIME '�� MIN SEC MIN SEC MIN SEC MIN 9EC IF SYSTEM FLOODED, LIST T1ME WATER REACHED TEST OPEkING ' " MIN Q SEC MIN sEC Mlr� SEC MIN _ SE�C PERFORMANCE �C1� INTERIOROF BODY �� _ MOVING PARTS � __ VALVE CONDITION RU68ER FACING SEATS � RESET? �/ DID ALARMS OPERATE Al" TRIP TEST? �C� ALL LOW POINT DRAINS BLOWN OUTi ' /Z� WATER CONTRdL VALVE LEFT �� OPEN AND SEALED? .. � . ALARM CONTROL VALVE LEFT {/ OPEN AND SEALED? / �� QUICK OPENING DEVICES SYSTEM NO. ( ) SYSTEM N0. ( ) SYSTEM NO. ( ) SYSTEM N0. ( ) DEVICE SERIAL NUMBER ��Q-� MANUFACTURER INAME) TYPE AND MODEL `- ' AIR PRESSURE IN URPER CHAMBER �B5 Les LBS LBS __ � - QUICK OPENING DEVICE TRIPPED AT sec �es sec �as sEc �es sEc �ee PERFORMl�NCE fJC'7 QUICK OPENING DEVICE LEFT IN SERVICE �� AND CONTRO� OPEN AND SEALED7 _ LIST ANY UNSATISFACTORY CONDITIONS: REMARKS: DIS7RIBUTIC�N: Whife to Owner - Canary & Pink to Appreving Agent - Gold to NaTional Fite ■ ENGINEERS i FABRICATORS ■ INSTALLERS 95 (iF.NF:RA1.INFnRMA7'It)N 1�-9 ,�-r+yyi a�.�a�,.++., . . CONTRACfiOR'S MATERIAL d�T�ST CERTIFtCATE FOR .A80VEOROUND PIPINO IIOClbtlllE . .�.,, tMe�i+ianW�Mon erwo►k,�mpreNon�nd twa Ni�lt w nNtl�e bv eM eonenoeer9 r�p►�MM�etw M,d w�m�N11 bv�n ewna'�t+nrwm�trw. A��--.__. . dlihlf11M11 W eenrOt�d M►d_r1NMh►.N/t ie�avla b�lon aentnoter'�OpNnaN Htilly INw M�Iob. . A Cwti/latf N�NI 6�ftll�tl eut�nd tipn�d bv boM npmMt�thrn. CoPiM thN1 b�pMpN�d far��PP►ov�M wthaieN�,owMn a�d oontnetor:" It N uMNFttaod tM own�r't npnant�tfw'��i�n�tun in no ww PrNudiq��ny qaNn pN1Mt o0ntt�eto►tw 1Why nNq►bl,pea wwknwMhip. a fWlun to eomply with�pprovin�wthaity�►pulnrMnu a IoeN ordin�noM. 7 �.� . R0► 11TV A ON S � � � � � � � � � . fi �,L � � � � .. G ACCt�T[D�Y A�► V INO AUTMp111 �I('!)NAMt� �� . ADDREf3 �.� � PLANS WSTALLATION CONfORMf TO ACC�PT[D CLANS E$ [�NO . EGUIMNENT USED 1S APPAOVlO 8 �NO � IF NO.[XPlA1N OtV1AT1AN1 . . . . . - � � � NAS PERSON IN CHANO!OF FIRQ�qUl►MENT OEEN INSTNUCTEO AS TO LQCATION � � OF CONTROC VAWtf AND CA11( NO MAINTtNANC[01 TNI!N[W EDUIPM<MT �� ❑NO . IR NO,ExCLA1N • � . � . � � If1:TRlJCT10N= C s p AND NI�PA 13A�EEN LEFT ON�EMIfEf TIONf AND CAl1E ANO MAIMTtNANCE CMAIITf ES NO . � .. IF NO,EXVLAIN . . � • �pCAT10N SUPPUES B1.065. dF fYtTfM r MAKE MQDEI �E�A O OMIfICE pVANtiT� TEMVERATURE MIWUFACt�II 1 qATikO �a ..._w.�.._.. i►MINKLERs �t �t N '�.� v ` -O � �� PI�E CONRORM�TO lTANOARO E� �NO ►ME AND fITTINpf CONFOIlM TO TANOAIID Ef []NO � � � .�fITTINOs IF NO.EXPlI11N � . ALApMDEVIC4 ' ' MAXMNlM7MA/ O�tM'fE711t101XiN?'EdTP1VE ��ALApM TypE ' MAK! MOD[L.. - - :...MIN. flC. VALVE OII fLON� ` 11�ICATOR M � TIME T WAT6R Alll ' T�II►POINT AEACHEO RATED TNl1U TEft MP IIEsiUNE ��EqU11R AM11116�fU11E rp�pEq�y OIIV►DE MIN. S[C �il f�G vEs r10 OI►t11ATIN0 '_ T[fT WlMout �.O.D. w�tn Q.O.D. �F no.exvu►�N � � IIAtIJNED RIlOM TIME INSPECTOq'S TEST�1►i ta OPENEO. �I{(OiY) ►qINTEb IN USA (OVLR) ^', � q�� Coetnetoi'�Materi�l A�Ta�CertiBcate for Abovetrow�d Pipia� �,��''. a y . , . � 1�-�d st�kINKIJ�,R 4}'.RI'Y.M!1 ..�.. OVERATiON - �� ----- ❑PNEUMA7IC ❑ELECTRIC ❑HVDRAUUC viOl UpERVISEC� �yES UNO UtI�ECTINOMEDIASUPEFVi5E0 � yE uNO DOES VAIV ERAT FqOM THE MqNU/�l TRIP ANO/OH iIEM f CONTROL STA OEIU�E b �3 TNERQ AN ACCES ACiLITv�N EnCH ciRCuit�Oq TEf O,EXIIAIN PqEACf ION �_]VES VALVE� _�___ ____ _ �- -- - ' - - �.� _..___.___ DOFS F/1CM CIACUII MAKIMUM TIM O MAKE OEL Sutavisicxv u,as nVar� p�qpAT�q�� ES NU VES `� NU SfC. N VQf�Q�TAu'I, Hydra�T�ht tNt��h�ll b�m�d��t nat IeN thm�Op p�;(1 J g b�r��lor two houn or 50 pu (J.4 b�n)Wov�tt�tie p�i+sur��n ixnu ot 150 pu 110 2 b�nl for two Aours. D�II�r�ntiN dry�pip�vNN cl�pert�n�ll b��rh op�n durinp tNt to pr�ant d�rt+p�. An�booe �ou�d p�p�np leskaqs�h�11 b��top0�d. TE8Y F NI Fiow th�.squued rs�e unul weter��d�ir�t indrcnb by no eou�ct,on o�fore�gn m�ta�ia�in burl�p bpt�t outl�q wch N OESCRFVTItlN hy r�nrt�nA blowoflS. Flu�h�t Ilow�nqt I��th�n O(�GPM(1B11�/minl for��rr�p�p� (i00 GPM IY�71 L/m�nl for 6�i�ch p�p�, 7y0 GPM 17HJ9 l/m�nl ior B��nch p�pe,1000 GPM IJ%86 L/minl lor 8��nc�D�p•. 1SU0 GPM i587B Um�nl fo� t0anch pip�md I000 GPM�75�0 L/m�n)for l��,nch P�p� Whnn�upp1V tlnnOt prpAut!ftipulal�d llow re�e:,��bra�n msx�mum ev��i�bi�. E�ubi�eh�0 n+�11.7 b�ri)�Ir p�e�wr��d me�wr�drOD wh�eh fhill not e�rr•M 1 'b nti 10 1 ban)in 2�1+ourf. T�rt pre�wrn��n i�t no.mai waur iev�l�nd ur p��fui�end m��fur��ir prn�wre drop Wh�ch�h�ii riot awce�d t•'h p�i(0.)b�n)in N how�. �_..�__._... . . .._._.�--..__._._----�-------- -�---------�-� ni.�nin,N,��vnnosrnricni�vtNrsp�r"�,pQ_P!I 1'CIq ,_,Z.WqR. �rN�� f�TArfqvAl4N [�Mrnin�Ntl1�+NE�uMATiCA�.l,r rK1lfAtl �/� (:�)rfe � _�NO FQUIPMl�N1 OPENATES pR[JPEqLy LJ rE$ uNU _'_�-� �A� AEADINC OF QAGE LOCATED N �AiER SUfi�I.V TEST PIVE: pE51WAL PR WITH VALVE IN TEST GIPE OPEN W�DE Tftt! TEST 57ATIC PRESSURE �-��— p51 VSP — ---_.._---_ _--..__..._------- -----._._� U��d�rqround m�inf�nd t��d in co�nectioni to�y�t�m ri��n flu�h�d bNor�connsction mad�to fprinkl�r pipinp. VERIFIED SV COCV O�1Nf U IORM NO.�SB ❑VE9 i_�p �T�+Ea gxp�qiN � FIUSHEO SV INSTALI.EA OF UNOE11• QHOUNp SPRINKIER PIPINO l�_�YES �_YNO v /7'� /�'f'y//^S� _._.�..__.. . _._ _ . __._.__'�._'. '__��____..._.._..__'. --I.r _..r v l�LL�^_' _l�LAR'�K S'FLYINO NUM6€ii U'T�Eh LOCATION9 __.___'.___... NUMOEq pEM�7VE0 c7AAiKH FS NELOEO P�PINp C VES C O ~ _ _ iF vES. b0 VOU CERTIFV q5 TNE SPRtNKLER CONTRAC�Op THq7 WELDiN6 PqOCEOliRES COMPLV WITM TME REQUIREMENTS OF qT IEASl NWS D10,9,LEVEI.AR•3 ❑VES ❑NO DO�OU f,EFTIFV TNAT 7NE WELbIN.WAS PERFOpMEO B�'WE�.DERS QUAUFI&D IN ��"' �' COMP1_IANCF WIi11 TNE NF.pU1Rf.MENTS OF AT LEAST AWS 1�10.9,IEVEL ARJ. ❑VES �NO DO vQU CEqTIFV T11AT WELDINO Wq3 CARf11E0 OV1 IN�OMVLIANCE WItN A f!r)CtiMFNTF.D QVALRV MNtAOL npqCEUU1IF. 1C�N3U�7E rw�f��L UiScf Aq! M[tN�hVCq� I��At c)P�NINOf IN VVINO A11R lMOUtH,T��4T�LA4 AND UfN�p W[l.U1N/� RESIDUt Aq[ �fMUV[O,ANO TNA1 TH!INiFANAL UTAMLT[A�Ur � _ PiP�N�i ARE NpT PENEfqA�ED �YES ��NO �}-0YCFAULIf. ��AMEPI.ATEVROVIUEq IFNO,EXPLAIN UATA _►IAMENLAT! ES ❑NO � � OATE LEfT IN SERVICE WITH ALL CONTROL VALVES UPEN: �— . f7EMAhKS ..,_. . .�, . - --_...._�.---'-- -•-�---�� --,.�..__._.�.__.__...__..__.._...-`-----�--'-----'----�--�`--.r___._. ._-- �---^- NAME UI lPRINKLCR CUNT RACT011 ' .�L11t�73�.�-�_.�-- t�—wt+�,�--�__-5 �c��..��._ TEST!WITNE�o er SIC�:J1TJqE5 FOR OPEqTV OW ( IpNED) TITI. OATE . � � a3a3 FOft SD lER NTRAC O 516 ) TI DATE AOUIT�ONqL EXPLqNATI N AryD NOTE ��/ � ., � ��,��.+d' � . � . . . . . .. . ... , ; , _. � . +�'�t. .. . . , � r • . . �,�y�+. i � ff �' ' : aSA�.p�F'._...... _.V.__._�__ _ _' Contractnr'�Materia)6e Test Certificate for Above6round Pipin6 �r�� 1301 L'Orient Street ('� � St.Paul,Minnesota 55117 �� (651)558-3300 • (800)229-6263 AUTOMATlC SPRINKIER C4. Fax: (651)558-3310 Settin,�; "I'he Standard... � AGREEMENT AND REPORT OF INSPEC'I'ION SHEE�L of 2-Use sepaeate sheet for each building insExcted #INSPECTION MINNESOTA LICENSE NO.C005 REPORT TO BUILDING OR LOCATION STREET INSPECTOR CITY&STATE DATE Owner hires Viking Automatic Sprvlkler Compviy to conduct an inspection of the fire suppression system at the aUove location or buildirtg,and prepare a written report of that inspecHon for an agreed upon fee. As part of this agreement,owner agrees to tern�s and conditions on rear of form and will complete the Owner's Section of 8iis�9ocument. Owner's Section(To be answered by Owner or Occupant) A. Explain any occupancy hazard changes since the previous inspection: B. Describe fire protecHon modifications made since last inspecHon: C. Describe any fires since last inspection: D. When was the system piping last checked for stoppage,corrosion or foreign material? E. When was the dry-pipinR system last checked for proper pitch? F. Are dry valves adequately protected fmm freezing? Si�ature Title Date Inspector's Section(All responses reference current inspection) N/A=NOT APPLICABLE 1 General a. Is the building occupied? n Yes �No b. Are all systems in service? a Yes :�No c. Does there appear to be a minimum of 18 in.(457 mm)clearance between the top of the storage and the sprinkler deflectors? t�Yes ❑No d. Does the valve hose on the sprinkler system(s)appear to Ue satisfactory? ❑Yes �i No n N/A 2 Control Valves(See Item 15) a. Do sprinkler system control valves appear to he in the appropriate open or closed position? .d Yes ❑No b. Are control valves in the open position locked,sealed or eyuipped with a tam,�er switch? ��_Yes ��No 3 Water Supplies(See Itern 16) a. Was a water flow test of main drain made at the sprinUer riser(s)? a Yes ❑No 4 Tanks,Pumps,Fire Departuient Connections a. Are fire pumps,�ravity tanks,reservoirs and pressure tanks in good condifion and properly maintained? n Yes ❑No ,�#N/A b. Are fire department connections in satisfactory condition,couplings free,caps in place,and check valves tight?�i Yes ❑No ❑N/A Are they accessible and visible? e Yes ❑No ❑N/A 5 Wet Systems a. Are cold weather valves(O.S.&Y.)in the appropriate open ar closed position? ❑Yes ❑No "�N/A b. Have antifreeze system solutions been tested? ❑Yes u No d N/A c. Were the antifreeze test results satisfactory? ❑Yes ❑No fl N/A 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 N/A Do all exteriar openings appear to be protected against freezing? ❑Yes ❑No o N/A 6 Dry System(See Items 11 to 13) a. Are dry valves(s)in service? e Yes ❑No ❑N/A b. Are the air pressures and primin�water levels in accardance with the manufacture's instructions? ❑'Yes ❑No ❑N/A c. Has the operafion of the air ar nitrogen supplies been tested?;Q Yes ❑No ❑N/A Are they in service? �Yes ❑No ❑N/A d. Were all lmow low points drained during this inspection? a Yes ❑No ❑N/A e. Did quick-opening devices operate satisfactorily?�Yes n No n N/A f. Did the dry valve(s)trip properly during the trip pressure test? u�-Yes ❑No u N/A Q. Did the heating equipment in the dry-pipe valve room(s)operate at Hme of inspection? erYes ❑No ❑N/A 7 Special Systems(See Item 14) a. Did the deluge or pre-ac6on valves operate properly dutting testin�? i i Yes i i No n N/A b. Did the heat-responsive devices operate properly during testing? ❑Yes n No .r�N/A c. Did supervisory devices operate during testing? ❑Yes ❑No , �N/A S Alarms a. Did water motor(s)and�on�(s)test sadsfactorily? i i Yes �,No ,�4 N/A b. Did electric alarm(s)test satisfactory? b Yes ❑No ❑N/A c. Did supervisory alarm service test satisfactory?,-h Yes ❑No ❑N/A 9 Sprinklers a. Do visible sprinklers appear to be free from corrosion,loadinQ or obstruction to spray discharge? o Yes ❑No b. Are sprinklers less than 50 years old? (Older sprinklers require sample testing);:o Yes ❑No c. Are quick response and residendal sprinklers less than 20 years old? (Older sprinklers require sample testing)„-a Yes ❑No n N/A d. Is stock of spare sprinklers available? a Yes ❑No e. Does the exterior condition of sprinkler system appear to be satisfactory?s o Yes ❑No f. Do visible sprinklers appear to be of proper temperature rating for their locations? n Yes �No 10 Explain any"No"answers and comments: Signature: Date: _� (Re�_�/a/o�) �e�ms �r�� i��ati�n� 1 This Agreement is for inspection services oniy. If Subscriber wants the Company to make any reF �' � alterations or replacements as a result of this inspection, the Company will do so for additional compensati: ' � be agreed upon in writing by the parties. 2 The Company does not know and does not represent whether the current fire protection system on the Proper�y was originally designed and installed in such a way that the system will perform as originally intended or is suitable and sufficient for its intended purpose gi�ien the way in which the Property has been or will be used. In other words, the Property has been or may be used in ways such that the configuration of partition walls, the lo�ation of and type of materials (including the presence of hazardous materiais) and other conditions of the Property's use are such that the fire protection system is inadequate, insufficient or unsuitable for the Property. THIS REPORT IS NOT A GUARANTEE OR WARRANTY THAT THE SYSTEM WILL IN ALL CASES (A) PROVIDE THE LEVEL OF PROTECTION FOR WHICH IT WAS ORIGINALLY INTENDED(B) IS FREE OF ALL DEFECTS AND DEFICIENCIES(C)AND IS IN COMPLIANCE WITH ALL APPICABLE CODES. 3 The Company's inspection will not include every sprinkler head, pipe or other parts of the fire protection sprinkler system that currently exist and is limited to a visual inspection of external readily accessible parts of the system. The Company shall only be obligated to inspect a representative number or sample of the sprinkler heads, pipes, hangers,valves or other devices and equipment in their current position. 4 The Company will be permitted, at all reasonable times, te enter the Property indicated above to conduct the inspection as outlined in this Agreement. 5 The Company's potential liability arising out of its inspection services must be limited. THEREFORE, THE LIABILITY, IF ANY, OF THE COMPANY TO THE SUBSCRIBER AND/OR OTHER OCCUPANTS OR VISITORS OF THE PROPERTY ARISING OUT OF THE COMPANY'S INSPECTION, REPORT, ACT OR OMISSION GR FAILURE TO ACT, OR ANY CLAIMED BREACH OF THIS AGREEMENT BY THE COMPANY, SHALL IN NO EVENT EXCEED THE TOTAL FEE PAID BY THE SUBSCRIBEf2 FOR THE INSPECTION SERVICES THAT GIVE RISE TO ANY SUCH LIABILITY. 6 The Company, following each inspection, will provide to the Subscriber a written "Report of Inspection" ("Report"). If required by state or local codes, the Company will provide a copy of the Report to fire and/or � building officials. If desired, a copy of the Report will also be fon�varded to the Subscriber's insurance company. The Report and recommendations by the Company are only advisory in nature and are intended to assist the Subscriber in reducing the possibility of loss to ;he Property by indicating obvious defects or impairments to the fire protection system(s) which were discovered by the Company's inspection and which should receive prompt attention. 7 Subscriber agrees to obtain and shall be soley responsible to maintain insurance for the Property, all contents therein,and/or operations performed within or around the Property to be inspected. 8 The Subscriber agrees to assume the e�tire responsibility and liability, to the fullest extent permitted by law,for all damages or injury to all persons, whether employees or otherwise, and to all property, arising out of it, resulting from or in any manner connected with, the execution of the work provided for in this Inspection Agreement or occurring or resulting from the use by the Company or its agents or employees of materials, equipment, instrumentalities or other property, whether the same be owned by the Subscriber, the Company or third parties, and the Subscriber, to the fullest extent permitted by law, agrees to indemnify and save harmless the Company, its agents and employees from all such claims including, without limiting the generality of the foregoing, claims for which the Company may be or may be claimed to be, liable and legal fees and disbursement paid or incurred to enforce the provisions of this paragraph and the Subscriber further agrees to obtain, maintain and pay for such general liability insurance coverage and endorsements as will insure the provisions of this paragraph. 9 While the Company will make every reasonable effort to prevent the discharge of water into or onto areas of landscaping, decorative pavement, etc., it is the Subscriber's responsibility to provide sufficient and readily accessible means to accept the full flow of water that may be required by tests as determined by the type of inspection. 10 This Agreement may not be assigned by Subscriber without the written consent of the Company. 11 This Agreement may be signed in counterparts; a signed facsimile, photocopy, and/or electronic mail of this Agreement shall be as binding on both parties just as though this Agreement were executed in its originai, pre- printed form. 12 If payment for work provided in this Agreement is not paid when due, Subscriber agrees to pay ail costs of collection including attorney's fees. (Rev.2/8/O6) . � r��°��rr�.� 1301 L'Orient Street � �� ' �*"' St.Paul,Minnesota 55117 AUTOMATIG SPRINK�ER CO. (651)558-3300 • (800)229-6263 Setti_r�`The Standard... Fax: (651)558-3310 � SHEET 2 oE 2-Use separate sheet for each system inspected System No.or Desc}�iption if multiple systems / �-�`� Inspection Repart No. -.,'Ci,�� ! � 11 Date dry-pipe valve trip tested(control valve partially open) ,f;'�� - "��, . ;� !=' (See Trip Test Table whicli follows) 12 Date dry-pipe valve trip tested(control valve fully open) �/ �, _ ��.„;� ( (See Trip Test Tnble wllich follows) 13 Date quick-opening device tested / �� . � ;_�:_ r� f? See Trip Test Table which follows) DRY VALVE TRIP TEST TABLE Q.O.D. MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO. � ' f� � � C� ' / r I4 �.� DRY P1PE Time to Trip Water Air Trip Point Time Water Reached Alarm Operatecl OPERATING Thru Test Pipe Pressure Pressure Air Pressure Test Outlet Properly TEST MIN. SEC. PSI PSI PSI M1N. SEC. YES NO Without Q.o.D % < < � ? y _ ._ (/ w�ch Q.O.D 14 Date deluge or preaction valve tested � �-� (See Trip Test Table w{iich follows) TRIP TEST TABLE Oper�tion ❑PNEUMATIC u ELECTRIC n HYDRAULIC Piping Supervised � YES c NO Detecting Media Supervised ❑ YES � NO DELUGE& Does valve operate from the manual trip and�or remote control stations ❑ YES ❑ NO PREACTION Is there an accessible facilitv in each circuitfor testing ❑ YES ❑ NO Method of Testing Circuits VALVES Does each circuit operate Does each circuit Maximum time to MAKE MODEL supervision loss alarm operate valve release operate releasc YES NO YES NO YES NO 15 See Control Valve Maintenance Table CONTROL VALVE MAINTENANCE TABLE Explain Abnormal Control Valves Number Type Open Secured Closed Signs Condition Cit Control Valves B ass Valves Tank Control Valves Pum Control Valves SecHonal Control Valves S stem Control Valves i <J " - Other Control Valves Kitchen Control Valves 16 Water Flow Test at Sprinkler Riser Water Su 1 Source: �t Tank Pum Residual Test Pipe Size of Static (Flow) Date Location Test Pi e Pressure Pressure Last Water Flow Test �� /�� i;' < `� � 'f� � �� This Water Fiow Test % � � 17 Explain any°No"answers and comments: 18 Ad' stments or co rections ma e uring t is inspection: ;� �`�;�J , . ( �.� �' . � .; _ �+ S .� -� '— ' J eC E�!'J e4 /7 if; !d , 19 A though t ese comments are not t e resu t o an engineering review,t e o owing esira `le improvements are recommen ed: �. �% � Signature: ,�� `� ��..� -1-- Date: - t�'�' � ' �_, (Re�.2/s/ob� Terms and Limitations 1 This Agreement is for inspection services only. If Subscriber wants the Company to make any repairs, • _ � alterations or replacements as a result of this inspection, the Company will do so for additional compensation to be agreed upon in writing by the parties. 2 The Company does not know and does not represent whether the current fire protection system on the Property was originally designed and installed in such a way that the system will perform as originally intended or is suitable and sufficient for its intended purpose given the way in which the Property has been or will be used. In other words, the Property has been or may be used in ways such that the configuration of partition walls, the location of and type of materials (including the presence of hazardous materials) and other conditions of the Property's use are such that the fire protection system is inadequate, insufficient or unsuitable for the Property. THIS REPORT IS NOT A GUARANTEE OR WARRANTY THAT THE SYSTEM WILL IN ALL CASES (A) PROVIDE THE LEVEL OF PROTECTION FOR WHICH IT WAS ORIGINALLY INTENDED(B) IS FREE OF ALL DEFECTS AND DEFICIENCIES(C)AND IS IN COMPLIANCE WITH ALL APPICABLE CODES. 3 The Company's inspection will not include every sprinkler tiead, pipe or other parts of the fire protection sprinkler system that currently exist and is limited to a visual inspection of external readily accessibie parts of the system. The Company shall only be obiigated to inspect a representative number or sample of the sprinkler heads, pipes, hangers,valves or other devices and equipment in their current position. 4 The Company will be permitted, at all reasonable times, to enter the Property indicated above to conduct the inspection as outlined in this Agreement. 5 The Company's potential liability arising out of its inspection services must be limited. THEREFORE, THE LIABILITY, IF ANY, OF THE COMPANY TO THE SUBSCRIBER AND/OR OTHER OCCUPANTS OR VISITORS OF THE PROPERTY ARISING OUT OF THE COMPANY'S INSPECTION, REPORT, ACT OR OMISSION OR FAILURE TO ACT, OR ANY CLAIMED BREACH OF THIS AGREEMENT BY THE COMPANY, SHALL IN NO EVENT EXCEED THE TOTAL FEE PAID BY THE SUBSCRIBER FOR THE INSPECTION SERVICES THAT GIVE RISE TO l�NY SUCH LIABILITY. 6 The Company, following each inspection, will provide to the Subscriber a written "Report of Inspection" ("Report"). If required by state or local codes, the Company will provide a copy of the Report to fire and/or building officials. If desired, a copy of the Report will also be forwarded to the Subscriber's insurance company. The Report and recommendations by the Company are only advisory in nature and are intended to assist the Subscriber in reducing the possibility of loss to the Property by indicating obvious defects or impairments to the fire protection system(s) which were discovered by the Company's inspection and which should receive prompt attention. 7 Subscriber agrees to obtain and shall be soley responsible to maintain insurance for the Property, all contents therein,and/or operations performed within or around the Property to be inspected. 8 The Subscriber agrees to assume the entire responsibility and liability, to the fuilest extent permitted by law, for all damages or injury to ail persons, whether employees or otherwise, and to all property, arising out of it, resulting from or in any manner connected with, the execution of the work provided for in this inspection Agreement or occurring or resulting from the use by the Company or its agents or employees of materials, equipment, instrumentalities or other property, whether the same be owned by the Subscriber, the Company or third parties, and the Subscriber, to the fullest extent permitted by law, agrees to indemnify and save harmless the Company, its agents and employees from all such claims including, without limiting the generality of the foregoing, claims for which the Company may be or may be claimed to be, liable and legal fees and disbursement paid or incurred to enforce the provisions of this paragraph and the Subscriber further agrees to obtain, maintain and pay for such general liability insurance coverage and endorsements as will insure the provisions of this paragraph. 9 While the Company will make every reasonable effort to prevent the discharge of water into or onto areas of landscaping, decorative pavement, etc., it is the Subscriber's responsibility to provide sufficient and readily accessible means to accept the full flow of water that may be required by tests as determined by the type of inspection. 10 This Agreement may not be assigned by Subscriber without the written consent of the Company. 11 This Agreement may be signed in counterparts; a signed facsimile, photocopy, and/or electronic mail of this Agreement shall be as binding on both parties just as though this Agreement were executed in its original, pre- printed form. 12 If payment for work provided in this Agreement is not paid when due, Subscriber agrees to pay all costs of collection including attorney's fees. � (Rev.2/8/06) - _ __ _ 301 York Ave St.Paul,Minnesota 55130 V� �� N� (651)558-3300 • (800)229-6263 AU1�1ATIt SPWNKLER CO. Fax: (651)558-3310 AGREEMENT AND REPORT OF INSPECTION SHFFT 1 ul 2-Use separnte sheet for each building inspected #INSPECTiON �� ' �� MINNESOTA LICENSE NO.C005 REPORT TO = ;,,,, � ,J �, f�.' ,: BUILDING OR LOCATION < ,;^y-�� , STREET � i%.. ,'i ��'� t �� ,. 4_? INSPECTOR ;`�r�.�-t � r= �, ,� �'�'" CITY&S`I'ATE `'±.�i �_�. j�, DATE � - �� Customer hires Viking Automatic Sprinkler Company to conduct an inspection of the fire suppression system�t the above location or building,and 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 and will complete the Owner's Section of this docunlent Viking Automatic Sprinkler Company will not be held liable for incorrect or w�kown answers provided in the Owner's Section. Owner's Section(To be answered by Owner,Occupant or Customer) A. Explain any occupancy hazard chan�es since the previous inspection: � ,��-,,� B. Describe fire protection modifications made since last inspection: f ; C. Describe any fires since last inspection: d t u; :• �a D. When was the systein piping l�st checked for stoppage,corrosion or foreign material? �, ,�, � ,, �_; „ E. When was the dry-piping system last checked for proper pitch? F. Are dry valves adequately protected kom keezing? � "�� 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 , . . , . .�—�L+—,�R � �.�- ��' -�i; =�' t w t' . �r � t l.,j . .1 eT_{,. � t� _��-- ��.X:� Signaturc ��; I'iHc Uatc ;!' �/ ' Inspector's Section(All responses reference current inspection) N/A=NOT APPLICABLE 1 General a. Is the building occupied? i�'es ��No b. Are all systems in service? �Yes ❑No 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 d. Does the valve hose on the sprinkler system(s)appear to be satisfactory? ri Yes ❑No �N�A 2 Control Valves(See Item 15) a. Do sprinkler system contro]valves appear to be in the appropriate open or closed position? {�Yes u No b. Are control valves in the open posikion locked,sealed or equipped with a tamper switch? �-Yes i�i No 3 Water Supplies(See Iten�16) � � a. Was a water flow test of main drain made at the sprinkler riser(s)? r�es �:No 4 'I'anks,Pumps,Fim Department Connections a. Are fire pumps,gravity tanks,reservoirs and pressure tanks in good condition and properl��maintaineci? ❑Yes n No �''N�A 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 Are they accessible and visible?�Yes �-No ❑N�A 5 Wet Svstems a. Are cold wcather valves(O.S.&Y.)in the appropriate open or closed position? ❑Yes i_�No �N/A b. Have antifreeze system solutions been tested? ❑Yes �No �A c Wem the antifreeze test results satisf�ctory? ❑Yes ❑No �A 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? u Yes c No :�j(N�A Do all exterior openinys appear to be protected against freezing? ❑Yes u No �T�A 6 Dry System(See 1 tents 11 to 13) � a. Are dry valves(s)in service? I�tS'es c No ❑N�A b. Are the nir pressures and pri�nin�water levels in accordance with the manufacture's instructions? �Yes ❑No ❑N/A 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 d. Were all know low points drained during this inspection? �s ❑No u N/A e. Did quick-opening devices eperate satisfactorily? �'es u No ❑N�A f. Did thc dr��valve(s)trip properly during the trip pressure test? �Yes ❑No r i N/A g. Did the heating equipment in the dry-pipe valve room(s)operate at time of inspection? �Yes ❑No ❑N�A 7 Special Systems(See Iterri 14) a. Did thc dcluge or pre-action valves operate properly during testing? u Yes ❑No pCN/A b. Did thc heat-responsive devices operate properly during testing? ❑Yes ❑No ��A c Did supervisory devices operate during testing? �i Yes ❑No �IV/A 8 Alarms a. Did water motor(s)and gon�(s)test satisf�ctorily? n Yes ❑No �fV�A b. Did elecri-ic alarm(s)test s�tisfactory? �Yes u No �N�A c. Did supervisory alarm service test satisfactory? �CYes a No ❑N/A 9 Sprinklers a. Do visible sprinklers�ppear to be free from corrosion,loading or obstruction to spray disch�rge?�QCYes �No b. Are sprinklers less than 50 years old? (Older sprinklers require sample tes6ng)�es i-i No c Are quick response and residential sprinklers less than 20 years old? (Older spxinklers reyuire sample testing) u Yes c No �I/A d. Is stock of spare sprinklcrs available? �5`es n No e. Does the exterior eonc�ition of sprinkler systein appear to be satisfactory? �CYes o No f. Do visible sprinklers appcar to be of proper temperature rating for their locations? �,Yes ❑No 10 Explain any"No"answers and comments: . � � �� —� Signature: �ti,�y,�/ Datc: ' (Re��-9/0'_/119) ��rrns and L�a��itir�ns � . 1 This Agreement is for inspection services only. If Customer wants Viking Automatic Sprinkler Company, herein after referred to as the Company,to make any repairs, aiterations or replacements as a result of this inspection, the Company will do so for additional compensation to be agreed upon in writing by the parties. 2 The Company does not know and does not represent whether the current fire protection system on the Property was originally designed and installed in such a way that the system will perform as originally intended or is suitable and sufficient for its intended purpose given the way in which the Property has been or will be used. In other words, the Property has been or may be used in ways such that the configuration of partition walls, the location of and type of materials (including the presence of hazardous materials) and other conditions of the Property's use are such that the fire protection system is inadequate, insufficient or unsuitable for the Property. THIS REPORT IS NOT A GUARANTEE OR WARRANTY THAT THE SYSTEM WILL IN ALL CASES (A) PROVIDE THE LEVEL OF PROTECTION FOR WHICH IT WAS ORIGINALLY INTENDED(B) IS FREE OF ALL DEFECTS AND DEFICIENCIES(C)AND IS IN COMPLIANCE WITH ALL APPLICABLE CODES. 3 The Company's inspection will not include every sprinkler head, pipe or other parts of the fire protection sprinkler system that currently exist and is limited to a visual inspection of external readily accessible parts of the system. The Company shall only be obligated to inspect a representative number or sample of the sprinkler heads, pipes, hangers,valves or other devices and equipment in their current position. 4 The Company wili be permitted, at al! reasonable times, to enter the Property indicated above to conduct the inspection as outlined in this Agreement. 5 The Company's potential liability arising out of its inspection services must be limited. THEREFORE, THE LIABILITY, IF ANY, OF THE COMPANY TO THE CUSTOMER AND/OR OTHER OCCUPANTS OR VISITORS OF THE PROPERTY ARISING OUT OF THE COMPANY'S INSPECTION, REPORT, ACT OR OMlSSION OR FAILURE TO ACT, OR ANY CLAIMED BREACH OF THIS AGREEMENT BY THE COMPANY, SHALL IN NO EVENT EXCEED THE TOTAL FEE PAID BY THE CUSTOMER FOR THE INSPECTION SERVICES THAT GIVE RISE TO ANY SUCH LIABILITY. 6 The Company, following each inspection, will provide to the Customer a written Report of Inspection ("Report"). If required by state or local codes, the Company will provide a copy of the Report to fire and/or building officials. If desired, a copy of the Report will also be forwarded to the Customer's insurance company. The Report and recommendations by the Company are only advisory in nature and are intended to assist the Ciastomer in reducing the possibility of loss to the Property by indicating obvious defects or impairments to the fire protection system(s)which were discovered by the Company's inspection and which should receive prompt attention. 7 Customer agrees to obtain and shail be solely responsible to maintain insurance for the Property, all contents therein, and/or operations performed within or around the Property to be inspected. 8 The Customer agrees to assume the entire responsibility and liability,to the fullest extent permitted by law, for all damages or injury to all persons, whether employees or otherwise, and to all property, arising out of it, resulting from or in any manner connected with, the execution of the work provided for in this Inspection Agreement or occurring or resulting from the use by the Company or its agents or employees of materials, eGui�ment. instrumentalities or other property, whether the same be owned by the Customer, the Company or third parties, and the Customer, to the fullest extenl permitted by law, agrees to indemnify and save harmless the Company, its agents and employees from all such claims including, without limiting the generality of the foregoiny, claims for which the Company may be or may be claimed to be liable and legal fees and disbursement paid or incurred to enforce the provisions of this paragraph and the Customer further agrees to obtain, maintain and pay for such general liability insurance coverage and endorsements as will insure the provisions of this paragraph. 9 While the Company will make every reasonable effort to prevent the discharge of water into or onto areas of landscaping, decorative pavement, etc., it is the Customer's responsibility to provide sufficient and readily accessible means to accept the full flow of water that may be required by tests as determined by the type of inspection. 10 This Agreement may not be assigned by Customer without the written consent of the Company. 11 This Agreement may be signed in counterparts; a signed facsimile, photocopy, and/or electronic mail of this Agreement shall be as binding on both parties just as though this Agreement were executed in its original, pre- printed form. 12 If payment for work provided in this Agreement is not paid when due, Customer agrees to pay all costs of collection including attorney's fees. (Rev.9/02/09) ��"'�� 1301 L'Orient Street St.Paul,Minnesota 55117 AUTUMATIC SPi71NKLER Cfl. (651)558-3300 • (800)229-6263 Settin�; The Standard... Fax: (651)558-3310 SHEET 2 of 2-Use separate sheet far each system inspected System No.or Descrip 'on i�ultiple systems /_ r� Inspection Report No. � � :,�"'�� 11 Date dry-pipe valve trip tested(control valve partially open) J�> -,� (_ � � (See Trip Test Table u�hich follozos) 12 Date dry-pipe valve trip tested(control valve fully open) % !_ .. � q (See Trip Test Tnble whicli folloins) 13 Date quick-opening device tested � � . �, _ �;� �j (See Trip Test Ta le zuhic}�follows) D�zY vALVE TRIP TEST TABLE Q.O.D. MAKE MODEL SEIZIAL NO. MAKE MODEL SERIAL NO. l' f Z [ � ., �, ti_- DRY PIPE Time to Tri� Water Air Trip Point Tiine Water Reached Alarm Operated OPERATI NG Thru Test Pipe Pressure Pressure Air Pressure Test Outlet Properly TEST MIN. SEC. I'SI PSI PSI M1N. SEC YES NO w�cr,� Q.o.� / � � �' =� � � ' `�� ,. w�rt, Q.o.� 14 Date deluge or preaction valve tested � � (See Trip Test Tnble wliidi folloms) TRIP TEST TABLE Oper�tion ❑PNEUMATIC ❑ELECTRIC ❑HYDRAULIC Piping Supervised ❑ YES ❑ NO Detecting Media Supervised �� YES ❑ NO DELUGE& Docs valve operate from the manual trip and�or remote control stations �� YES ❑ NO PREACTION Is there an accessible facility in eoch circuit for testing � YES n NO Method of'Cesting Circuits VALVES Does eadi circuit oper�te Does each circuit Maximum time to MAKE MODEL supervision loss alarm operate valve release operate release YES NO YES NO YES NO 15 See Control Valve Maintenance Table CONTROL VALVE MAINTENANCE TABLE Explain Abnormal Control Valves Number Type Open Secured Closed Signs Condition Cit Control Valves B �ass Valves Tank Control Valves Pump Control Valves Sectional Control Valves Svstem Control Valves ? - �' �'S �� Q < r:�S Other Control Valves Kitchen Control Valves 16 Water Flow Test at Sprinkler Riser ,�.,., ;� Water Su 1 Source: �Cit } , Tank Pum " Residual Test Pipe Size of Static (Flow) Date Location Test Pi e Pressure Pressure Last Water Flow Test � �/� ,. r �:��<�.. � '` �, !! This Water Flow Test _ --��7 ; �� > ' /� -i 17 Explain any "No"answers and comments: 18 Adjustments oz�corrections made during this inspection: _. ��)��;;; j- �; d%� f��.:,�, ��,;_( j%�; �tf,� �, _.... — r l s t;r �s ' -:�- � 5 �<�t � —_ � � ` � ><�. � .� k c ��f'< �!:;� �-- 19 Althoug fllese comments are i�ot t e result o an engineering review,the o owing desira le improven�ents are recoinmended: Signature: �� Date: fr� - /�.- - (°�`� (Rev.2/8/06) Terms and Limitationc- J ' 1 This Agreement is for inspection services only. If Subscriber wants the Company to make any repairs, alterations or replacements as a resuit of this inspection, the Company will do so for additional compensation to be agreed upon in writing by the parties. 2 The Company does not know and does not represent whether the current fire protection system on the Property was originally designed and installed in such a way that the system will perform as originally intended or is suitable and sufficient for its intended purpose given the way in which the Property has been or will be used. In other words, the Property has been or may be used in ways such that the configuration of partition walls, the location of and type of materials (including the presence of hazardous materialsl and other conditions of the Property's use are such that the fire protection system is inadequate, insufficient or unsuitable for the Property. THIS REPORT IS NOT A GUARANTEE OR WARRANTY THAT THE SYSTEM WILL IN ALL CASES (A) PROVIDE THE LEVEL OF PROTECTION FOR WHICH IT WAS ORIGINALLY INTENDED(B) IS FREE OF ALL DEFECTS AND DEFICIENCIES(C)AND IS IN COMPLIANCE WITH ALL APPICABLE CODES. 3 The Company's inspection wiil not include every sprinkier head, pipe or other parts of the fire protection sprinkler system that currently exist and is limited to a visuai inspection of external readily accessible parts of the system. The Company shall only be obligated to inspect a representative number or sample of the sprinkler heads, pipes, hangers,vaives or other devices and equipment in their current position. 4 The Company will be permitted, at all reasonable times, to enter the Property indicated above to conduct the inspection as outlined in tnis Agreement. 5 The Company's potential liability arising out of its inspection services must be limited. THEREFORE, THE LIABILITY, IF ANY, OF THE COMPANY TO THE SUBSCRIBER AND/OR OTHER OCCUPANTS OR VISITORS OF THE PROPERTY ARISING OUT OF THE COMPANY'S INSPECTION, REPORT, ACT OR OMISSION OR FAILURE TO ACT, OR ANY CLAIMED BREACH OF THIS AGREEMENT BY THE COMPANY, SHALL IN NO EVENT EXCEED THE TOTAL FEE PAID BY THE SUBSCRIBER FOR THE INSPECTION SERVICES THAT • GIVE RISE TO ANY SUCH LIABILITY. 6 The Company, following each inspection, will provide to the Subscriber a written "Report of Inspection" ("Report"). If required by state or local codes, the Company will provide a copy of the Report to fire and/or building officials. If desired, a copy of the Report will also be forwarded to the Subscriber's insurance company. The Report and recommendations by the Company are only advisory in nature and are intended to assist the Subscriber in reducing the possibility of loss to the Property by indicating obvious defects or impairments to the fire protection system(s) which were discovered by the Company's inspection and which should receive prompt attention. 7 Subscriber agrees to obtain and shall be soley responsible to maintain insurance for the Property, all contents therein,and/or operations performed.within or around the Property to be inspected. 8 The Subscriber agrees to assume the entire responsibility and liability, to the fullest extent permitted by law, for all damages or injury to all persons, whether empioyees or otherwise, and to all property, arising out of it, resulting from or in any manner connected with, the execution of the work provided for in this Inspection Agreement or occurring or resulting from the use by the Company or its agents or employees of materials, equipment, instrumentalities or other property, whether the same be owned by the Subscriber, the Company or third parties, and the Subscriber, to the fullest extent permitted by law, agrees to indemnify and save harmless the Company, its agents and employees from all such claims including, without limiting the generality of the foregoing, claims for which the Company may be or may be claimed to be, liable and tegal fees and disbursement paid or incurred to enforce the provisions of this paragraph and the Subscriber further agrees to c,btain, maintain and pay for such general liability insurance coverage and endorsements as will insure the provisions of this paragraph. 9 While the Company will make every reasonable effort to prevent the discharge of water into or onto areas of landscaping, decorative pavement, etc., it is the Subscriber's responsibility to provide sufficient and readily accessible means to accept the full flow of water that may be required by tests as determined by the type of inspection. 10 This Agreement may not be assigned by Subscriber without the written consent of the Company. 11 This Agreement may be signed in counterparts; a signed facsimile, photocopy, and/or electronic mail of this Agreement shall be as binding on both parties just as though this Agreement were executed in its original, pre- printed form. 12 If payment for work provided in this Agreement is not paid when due, Subscriber agrees to pay all costs of coliection including attorney's fees. (Rev.2/8/O6)