49 FEDERAL STREET - ABOVE GROUND SIGNEDContractor’s Material and Test Certificate for Aboveground Piping
Procedure: Upon completion of work, inspection and tests shall be made by the contractor’s representative and witnessed by
an 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. 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.
Property Name:
Property Address: Date:
Plans
Accepted by Approving Authorities (Names):
Address:
Installation conforms to accepted plans: Yes No
Equipment use is approved: Yes No
If no, explain deviations:
Instructions
Has person in charge of fire equipment been instructed as to
location of control valves and care and maintenance?: Yes No
If no, explain:
Have copies of the following been left on the premises?:
1. System components instructions Yes No
2. Care and maintenance instructions Yes No
3. NFPA 25 Yes No
Location of
System
Supplies Buildings:
Sprinklers
Make Model Year of
Manufacture Office Size Quantity Temperature
Rating
Pipe and
Fittings
Type of Pipe:
Type of Fittings:
Alarm Valve
or Flow
Indicator
Alarm Device Maximum Time to Operate
Through Test Connection
Type Make Model Min Sec
Dry Pipe
Operating
Test
Dray Valve Q.O.D.
Make Model Serial # Make Model Serial #
Time to Trip Through
Test Connection
Water
Pressure
Air
Pressure
Trip Point
Air Press.
Time Water Reach
Test Outlet
Alarm Operated
Properly?
Min Sec PSI PSI PSI Min Sec Yes No
Without Q.O.D.
With Q.O.D.
Deluge and
Preaction
Valves
Operation: Pneumatic Electric Hydraulic
Piping Supervised? Yes No Detecting Media Supervised? Yes No
Does valve operate from the manual trip, remote, or both control stations? Yes No
Is there an accessible facility in each circuit for testing? Yes No
If no, explain:
Make Model
Each Circuit Operate Supv. Loss Alarm? Each Circuit Operate Valve Release? Maximum Time to Operate Release
Yes No Yes No Min Sec
Revised: 2013-May-02 Building Inspections Forms and Handouts
G:\DSDSystem\Handouts\Building\Plumbing\ContractorsAboveGroundPiping.docx Page 2 of 2
Pressure
Reducing
Valve Test
Location &
Floor
Make &
Model Setting Static Pressure Residual Pressure (Flowing) Flow Rate
Left (psi) Outlet (psi) Inlet (psi) Outlet (psi) Flow (gpm)
Test
Description
Hydrostatic: Hydrostatic tests shall be made at not less than 200 psi (13.6 bars) for 2 hours or 50 psi (3.4 bars) above static pressure in excess of 150 psi (10.2 bars) for 2 hours. Differential dry-pipe valve clappers shall be left open during the test to prevent damage. All aboveground leakage shall be stopped. Pneumatic: Establish 40 psi (2.7 bars) air pressure and measure drop, which shall not exceed 1 ½ psi (0.1 bars) in 24 hours. Test pressure tanks at normal water level and air pressure and measure air pressure drop, which shall not exceed 1 ½ psi (0.1 bars) in 24 hours.
Tests
All piping hydrostatically tested at _____psi _____ bars for ______hrs If no, state reason:
Dry piping pneumatically tested Yes No
Equipment operates properly Yes No
Do you certify as the sprinkler contractor 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? Yes No
Drain Test Reading of gauge located near water supply test connection: ____psi (___bars) Residual pressure with valve test in connection open wide: ____psi (___bars)
Underground mains and lead in connections to system risers flushed before connection made to sprinkler piping:
Verified by copy of the U-Form No. 85B Yes No Other (explain):
Flushed by installer of underground sprinkler piping Yes No
If powder-driven fasteners are used in concrete, has representative sample testing been satisfactorily completed? Yes No
If no, explain:
Blank
Testing
Gaskets
Number Used Locations Number Removed
Welding
Welded Piping? Yes No If yes:
Do you certify as the sprinkler contractor that welding procedures comply with the requirements of at least AWS D10.9, Level AR-3? Yes No
Do you certify that the welding was performed by welders qualified in compliance with the requirements of at least AWS D10.9, Level AR-3? Yes No
Do you certify that welding was carried out in compliance with a documented quality control procedure to ensure that all discs are retrieved, that openings in piping are smooth, that slag and other welding residue is removed, and that the internal diameters of piping are not penetrated? Yes No
Cutouts
(Discs) Do you certify that you have a control feature to ensure that all cutouts (discs) are retrieved? Yes No
Hydraulic
Data
Nameplate
Nameplate provided? Yes No If no, explain:
Remarks Date left in service with all control valves open:
Test
Witnessed
By
Name of Sprinkler Contractor:
For Property Owner (signed) TITLE DATE
For Sprinkler Contractor (signed) TITLE DATE
Additional Explanation and Notes: