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HomeMy WebLinkAboutFAI21-0013 CF Annual sprinkler Inspection, Testing, and Maintenance Cover Sheet NFPA25 as amended by CCR, Title 19 Property Information: 111111.111111"- • Name: New Hovlid Cummunity Care Center Occupancy/Use: Address: 246 Spuce Construction Type: r�O 1./A r 1 x. 4 1 s �1xt+► City: Gridley No. Stories: 0 0 �3 Imo' y i 95948 + ' ZIP: Year Constructed: r+li 'c 1 P _tatty" Mike Newton �' y, , Contact: y = Telephone: (530)707-7687 Contractor Information: ll Number of System Risers Name: Voltage Specialists Copy sent to: Address: 370 Apple Lane E Owner Date: 04/26/21 City: Paradise ❑Fire AHJ Date: State: California ❑Contractor Date: (530)624-4514 NOTES: Telephone: 1)For specific inspection,testing, and maintenance 880862 requirements and information,see NFPA 25,2011 CA License#: Edition as amended by California Code of Regulations, Title 19,§901 to§906. Job#: 2)Inspection items may be performed by the owner in Performed by: Mat Machado accordance with California Code of Regulations,Title 19, §904.1(a) a Check box tor each system ins)erted and enter the number of forms used for inspection. Check boxes(Fail or Pass)to iridicate 5...us of inspected system at end of inspection. NFPA 25 —._ Forms Included with this Report s Chapter Number of Forms N/A Fail* Pas © Automatic Sprinkler System 5 0 ❑ ❑ 0 ❑ Standpipe and Hose System 6 0 [ ❑ Private Water Supply System 7 0 ❑ ❑ ❑ ❑ Fire Pump 8 0 0 ❑ ❑ ❑ Water Storage Tank 9 0 ❑ ❑ ❑ ❑ Water Spray System 10 0 ❑ ❑ ❑ ❑ Foam Water Sprinkler System 11 0 ❑ ❑ ❑ O Water Mist System 12 0 ❑ ❑ ❑ ❑ Concerns that are not deficiencies(i.e. Non-Sprinklered Areas) ❑ Yes 0 No 'See "Deficiencies and Comments"section at end of each respective form. AES 1 September 3,2013 Wet Pipe California Code of Regulations -Title 19 Quarterly and 1 of 3 Fire Sprinkler System Inspection, Testing, and Maintenance Annual Report Property Information ;� flF�aL�,�`�i� Contractor or Licensed Owner Information r.� II I •-* lyi°1 !Building Name New Hovlid Cummunity Care Center i H 3 -- Name Voltage Specialists 'Address Addr1. ess 370 Apple Lane ' 246 Spuce Mel'''. City Paradise St. CA Zip 95969 'City Gridley ''License# 880862 IPhone 530-362-2609 'Contact Person I ❑ SFM ',Job# I Mike Newton I 0 CSLB !Misc. Riser Information Main Drain Test(Annual) Location Riser Main Drain Initial Static Residual Final Static p,F,NIA Diameter Diameter Pressure Pressure Pressure 1 Central Storage I 4" I 2" I 1 I I I I I I I I I I I I I I I I I I I LEI This building has more than 5 risers. See additional AES 2.9 form attached Number of AES 2.9 forms attached I--I Quarterly Inspections 1 =Inspection T=Test M=Maintenance P=Pass F=Fail N/A =Not Applicable Item Mgr Description IMMe NFPA 25 CA ed. Date Date Date LDate Reference I 04/26/21 I I I I 1 - _1 1.1 I Control Valves—Identification Sign 13.3.1 P 1.2 I Control Valves—Inspection 13.3.2 P 1.3 I 'Waterflow Alarm Devices 5.2.5 P 1.4 I Supervisory Devices 5.2.5 P 1.5 I Gauges(Wet Pipe Systems) 5.2.4.1 P 1.6 I lEnter Water Supply Pressure Below Riser Check 5.2.4.1 psi psi psi psi 1.7 I lEnter Water Supply Pressure Above Riser Check 5.2.4.1 psi psi psi psi 1.8 I IPressure Readings Acceptable 5.2.4.1 P 1.9 I IHydraulic Design Information Sign 5.2.6 P (for hydraulically designed systems) 1.10 I 'General Information Sign 5.2.8 P (not required for system prior to 2007 edition of NFPA 13) 1.11 1 IHeat Tape 5.2.7 N/A 1.12 I :Spare Sprinklers 5.2.1.4 P 1.13 I IFire Department Connections 13.7 P 1.14 I Alarm Valves—Exterior Inspection 13.4.1 P 1.15 1 IPressure Reducing Valves 13.5.1.1 N/A J 1.16 I IBackflow Preventers 13.6.1 N/A 1.17 I Small Hose Connections-Hose Valve* 5.1.6, 13.5.2 N/A 13.5.5.1 1.18 I IPRV—Fire Sprinkler Systems 13.5.1.1 N/A III *Small hose connections are hose valves and optional hose supplied by the fire sprinkler system. They do not include Class I, II, or III standpipe systems. Form AES 2.1 Sept.3,2013 Wet Pipe California Code of Regulations -Title 19 Quarterly and 2 of 3 Fire Sprinkler System Inspection, Testing, and Maintenance Annual Report Property Information 4{uaF CAL4ointractor or Licensed Owner Information 7C ;a Vol�Zl 'Building Name New Hovlid Cummunity Care Center 4 3 b,' IName Voltage Specialists !Address 246 Spuce r41+ '`s�_ r Job# 'City Gridley �E..'�AE _'�- } ANNUAL INSPECTION, TESTING, AND MAINTENANCE Include ALL Quarterly Inspections = Inspection T =Test M=Maintenance P=Pass F=Fail N/A=Not Applicable Item 1Description CA ed. Date Comments Only P,F,N/A "riReference 1.19 I Sprinklers 5.2.1 1.20 I (Buildings(Freeze Protection) 4.1.1.1 I Owner's Responsibility 1.21 I IPipe and Fittings 5.2.2 1.22 I IHangers 5.2.3 I 1.23 I Seismic Braces 5.2.3 I 2.1 T (Field Service Test Required 5.3.1 I If REQUIRED, Enter'F'until (Send Report to Fire Code Official) results are returned from Lab 2.2 T Recalled Sprinklers Title 19 I If not present=Pass: If present=Fail 904.1(c) 2.3 T Water Flow Alarm Devices 5.3.3 I 90 sec.maximum - (Enter Time) 13.2.6 sec. Main T ain Drain Test 13.2.5 (Enter data on Page 1 of this form) 13.3.3.4 I 2.5 T Control Valve-Position 13.3.3.2 2.6 T {Control Valve—Operation 13.3.3.1 2.7 T Supervisory Devices 13.3.3.5 I 2.8 T 1Backflow Preventer Assemblies 13.6.2 2.9 T Small Hose Connections* 13.5.2.3 w/PRV Hose Valves—Partial Flow Test 13.5.3.3 2.10 T 1PRV—Fire Sprinkler Systems 13.5.1.3 3.1 M Control Valves 13.3.4 3.2 M Small Hose Connections* 13.5.6.3 I Obstruction Investigation required I 3.3 M (If"Yes", see Deficiencies and Comments Section for Results.) 14.3 I IR Yes No Isystem r3.4 M Returned to Service [ 4.5.3 I *Small hose connections are hose valves and optional hose supplied by the fire sprinkler system. They do not include Class I, II, or III standpipe systems. I D=Deficiency C=Comment (Indicate type) (tern. Date Riser D C Deficiencies and Comments Indicate all artuipment,devices and parts that n'Qra rrrrerrrd or repkacea [ I I II Im I 1 I r-rr Form AES 2.1 Sept.3,2013 Wet Pipe California Code of Regulations -Title 19 Quarterly and 3 of 3 Fire Sprinkler System Inspection, Testing, and Maintenance Annual Report Property Information sT;,r.oP CR �o Contractor or Licensed Owner Information Building Name New Hovlid Cumrnunity Care Center # Name Voltage Specialists Address 246 Spuce f / Job# City Gridley k. 1 = D=Deficiency C=Comment (Indicate type) Item Date Riser D C Deficiencies and Comments (cont.) Indicate all equipment,devices and parts that were repaired or replaced 1111 in • ❑Check here if additional Deficiencies and Comments are listed on Form AES9 Number attached: ❑See Correction Form AES 10 for corrected deficiencies. Number attached: I hereby certify that the fire protection equipment listed above has been fully inspected,tested,and maintained on this date by the company indicated above,in accordance with CCR, Title 19,Sections 901 to 906 and that the equipment is fully operable except as noted in the"Deficiencies and Comments"section of this form. Check box if Annual Inspection,Testing&Maintenance Items are Completed in the Indicated Quarter Charter 1st - ❑ Annual 2nd - Annual 3rd - Annual 4[h - Annual Date 04/26/21 Print Name Mat Machado Signature CPc Form AES 2.1 Sept.3,2013 voLTAG F � 370 Apple Lane, Paradise, CA 95969 Phone 530-624-4514 www.VoltageSpecialists.com State of Calif Fire/Life Safety#113568 Calif C10/C16 880862 NICET#87630 DIR 10000141915 Local 340 Live Scanned & Fire Life Safety Certified Personnel EP 5 QUARTERLY ALARM VERIFICATION TEST Orchard Hospital 4/26/21 Customer Test Date Hovlid CSM Site Monitoring Company 246 Spruce Street 40-3713 Address Account Number EST 5:21:55 5:36:32 Panel Type Panel Time Time Alarm Transmitted Pull Station 5:22:54 5:37:01 Device Tested Monitoring Co. Time Time Alarm Rec'd 29 seconds Biggs Gridley Time for Monitoring Company to Respond Fire Department 530-846-5678 Fire Dept Phone Number EC.02.03.05 EP 25 Testing Activity:EP 5:Emergency Services Notification Required Frequency of activity:Quarterly For additional guidance referenced NFPA standard(s):NFPA 72-2016 Edition;(Table 14.4.3.2) • INSPECTOR SIGNATURE CUSTOMER SIGNATURE TEST DATE: 14/26/21 Wet Chemical Pre-Engineered California Code of Regulations-Title 19 Semi-Annual 1 of 2 Fire Extinguishing System Inspection,Testing,and Maintenance Report Property Information �ruOF CA4��`fl Contractor or Licensed Owner Information IP•.''ding Name New Hovlid Community Care Center 3► a Name Voltage Specialists ess 246 Spruce ,'41 Address 370 Apple Lane NP City Paradise St. CA Zip 95969 'City Gridley 1License# 880862 (Phone (530)624-4514 'Contact Person Mike Newton I © SFM IJob# '(Phone 701-7687 I • CSLB 'Misc. System Information Cylinder Size 3 gal and 1 1/2 gal Last Hydrostatic Test Date Flow Points Capacity Used 13 System Location Wall next to the hood System Mfr. Ansul Model# R102 IFuei/Heat Shut Off: [Gas# Electrical# Integral Make Up Air Shut Down I. Items k of Items Dimensions J Nozzle Nozzle Nozzl Model# I Flow Points 1 Qty Flow Points 1 Hoods 1 10' I - I - I - I f(Plenums 1 1 I 10' I 1 N I 1 I 1 I 1 1IDucts I 1 I 2'x1 I 2W I 2 I 1 I 2 Cooking Appliances Left to Right with Sizes and Coverage Nozzles Appliance Name T Nozzle I Nozzle I Total Appliance Name Nozzle I Nozzle I Total Model Flow Points Flow Points I Model ! Flow Points Flow Points Range I 1 F I 1 I 3 I I I I I Griddle I 1N I 1 I 1 I I I I I Til skillet I 3N I 3 I 6 I I I I I I I II I I I I I I II I I I Fixed Temperature Sensing Elements (such as Fusible Links) luandty I Temp I Mfr Date I ID nstaltel Quantity Temp1 Mfr Date 1 ID nstaltel 3 1 450 I 2021 1 4/28/21 I I I I I I I Inspection,Testing and Maintenance 0 =Inspection T =Test M=Maintenance P=Pass F=Fail N/A=Not Applicable Rem I escription IIM NFPA 17A CA ed.Reference Date Comments Only I P,F,NIA I 1.1 I I anuaT ctuators are nobstructed 7.2.2(2) 04/28/21 I P (i.e.remote pull station) 1.2 I I 'Tamper Indicators&Seals Intact 7.2.2(3) 04/28/21 I I P ++ 1.3 1 I ([Maintenance Tag in Place I 7.2.2(4) 104/28/21 I I P ` Title 19 906 I 11 1.4 1 1 INo Obvious Physical Damage 7.2.2(5) 04/28/21 I I P 1.5 I I 'Gauge Readings within Proper Limits I 7.2.2(6) I f N/A (Stored pressure) 1.6 I I [Blow-off Caps in Place&Undamaged 7.2.2(7) 04/28/21 I I P 1.7 I I (Hoods,Ducts,Filters in Place and Clean CFC 904.11.6.3 104/28/21 I I P 1.8 I I IHood,Ducts&Protected Cooking Appliances Have 7 2 2(8) 104/28/21 I I P Not Been Replaced,Modified or Relocated 2.1 I T {��utomatic Detection/Manual Actuation Functioned I 7.3.3.4 104/28/21 I I P Lorrectly I (i AES 20 Sept 3,2013 Wet Chemical Pre-Engineered California Code of Regulations-Title 19 Semi-Annual Wir Fire Extinguishing System Inspection,Testing,and Maintenance Report Property Information Contractor or Licensed Owner Information P tding Name New Hovlid Community Care Center S Name Voltage Specialists ass 246 Spruce lil-94 Job# 4E rlty Gridley 1 MrInspection,Testing and Maintenance =inspection T =Test M=Maintenance P=Pass F=Fail N/A=Not Applicable Item 1 Deseriptionn ed.Referen e I e I Comments Only =P,F,NIA • 2.2 T Fuel Shut-off Operated Correctly 7.3.3.4 04/28/21 I I P 2.3 T Regulator Tested&is within Acceptable Limits 7.3.3.4 04/28/21 I P 2.4 T Manual Reset Relay Functioned Correctly 7.3.3.4 04/28/21 + P (if applicable) 3.1 M All Agent Containers within Acceptable Hydrostatic Test Dates 7,5.1(1) 04/28/21 I I P 3.2 M All Auxiliary Pressure Containers and/or Hose 7,5.1(2)(3) 04/28/21 I I P Assemblies within Acceptable Hydrostatic Test Dates _ 3.3 M Cartridge Weights within Acceptable Limits 7.3.3.1(2) 04/28/21 I I P 3.4 M Liquid Level within Acceptable Limits 7.3.3.1(2) 04/28/21 I I P (Non-pressurized) 3.5 M No Signs of Corrosion in Agent Cylinder 7.3.3.1(2) 04/28/21 I 1 P (Non-pressurized) 3.6 M Distribution Piping Unobstructed and Contiguous 7.3.3.1(3) 04/28/21 I I P 3.7 M Nozzles are Correct,Clean&Properly Aimed 7.3.3.1(2) 04/28/21 I 1 P 3.8 M Fixed Temp Fusible Metal Alloy Type Detectors Replaced 7.3.4 04/28/21 I I P 3.9 M Fixed-Temp(other than fusible metal alloy type) 7 3 5 I I N/A &Heat Detectors Maintained or Replaced 10 M Auxiliary Equipment Such as Water valves 7.3.3.1(2) I I N/A Functioned Correctly .,.11 M Internal Maintenance as Required by Manufacturer Title 19§904.7 I I N/A D=Deficiency C=Comment Indicate t .e Item Date Riser D C Deficiencies and Comments Indicate all equipment,devices and parts that were repaired or replaced I I. ®• ! I • ❑Check here if additional Deficiencies and Comments are listed on Form AES9 Number attached: ❑ See Correction Form AES 10 for corrected deficiencies Number attached: I hereby certify that the fire protection equipment listed above has been fully inspected,tested,and maintained on this date by the company indicated above,in accordance with CCR, Title 19,Sections 901 to 906 and that the equipment is fully operable except as noted in the"Deficiencies and Comments"section of this form. II Print Name I Tyler Rodgers Signature I Date 04/28/21 n AES 20 Sept.3,2013