ps-2011-00070ps-2011-00070_0002.tif ASSOCIATED FIRE PROTECTION
2316 South 24 Street Phone: (402) 733 -2800
Omaha, NE-68108 Fax: (402) 344 -7469
Contractor's Material & Test Certificate for Above Ground Piping
PROCEDURE:
Upon completion of work, inspection and tests shall be made by contractor's representative and witnessed by the owner's representative. All defects
shall be corrected and system left in service before contractor's personnel finally leave the job.
A certificate shall be filled out and signed by both representatives. Copies shall be prepared for approving authorities, owners, and contractor. If it is
understood the owner's representative's signature in no way prejudices any claim against contractor for faulty material, poor workmanship, or failure to
comply with approving authority's requirements or local ordinances.
S- 0 ( I Oo
PROPERTY NAME: Crowell Memorial Hospital DATE: 4/13/11
ADDRESS: 245 South 22 Street Blair, NE 68008
ACCEPTED BY APPROVING AUTHORITY (NAMES)
Nebraska State Fire Marshal
ADDRESS
PLANS 246 South 14 Street Lincoln, NE 68508
INSTALLATION CONFORMS TO ACCEPTED PLANS X YES _ NO
EQUIPMENT IS APPROVED _X YES — NO
IF NO. EXPLAIN
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION
OF CONTROL VALVES AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT X YES _ NO
IF NO. EXPLAIN
INSTRUCTIONS
HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES:
1. SYSTEM COMPONENTS INSTRUCTIONS _X YES _NO
2. CARE AND MAINTENANCE INSTRUCTIONS _X_ YES — NO
3. NFPA 25 X YES _ NO
LOCATION OF SUPPLIES BULDINGS:
SYSTEM Existing V Floor & Bulk Piping
MAKE MODEL YEAR OF ORIFICE QUANTITY TEMP.
MANUFACTURE SIZE RATING
Reliable F1 FR PENDENT 2010 Y2 100 155
Reliable F1 FR HSW 2010 Y2 59 155
SPRINKLERS Reliable F1FR UPRIGHT 2010 Y2 58 155
Reliable F1FR PENDENT 2010 Y2 2 200
Reliable F1 RES. 44 HSW 2010 %" 40 155
Reliable G4A CONCEALED PEND. 2010 '/2' 1 155
Reliable F3QR DRY PEND. 2010 Y2" 3 155
Reliable F1 FR VSW 2010 %" 3 155
Reliable F1 FR56 EC -8 HSW 1 2010 %2' 1 155
PIPE & TYPE OF PIPE – SCHEDULE 10, DYNATHREAD, & CPVC
FITTINGS TYPE OF FITTINGS – CPVC & DUCTILE IRON
ALARM DEVICE MAXIMUM TIME TO OPERATE
TO TEST CONNECTION
WET PIPE TYPE MAKE MODEL MIN. SEC.
DRY VALVE Q.O.D.
DRY PIPE MAKE MODEL SERIAL NO MAKE MODEL Serial No
TIME TO TRIP TIME WATER ALARM
THRU TEST WATER AIR REACHED OPERATED
CONNECTION' PRESSURE PRESSURE TEST OUTLET" PROPERLY
MIN I SEC I PSI PSI Min I Sec I YES I NO
W /Q.O.D.
IF NO EXPLAIN:
MEASURED FROM TIME INSPECTOR'S TEST CONNECTION IS OPENED