Park West CC(13)-LR 910912STATE BOARD OF INSD ANCE
P.O. BOX 149098
ENGINEERING SECTION (011-3)
AUSTIN. TEXAS 78714-9098
CONTRACTOR'S MATERIAL & TEST CERTIFICATE FOR
PROPERLY NAME !
PROPERTY ADDRESS
CONTRACTOR NAME
UNDERGROUNDPIPING
DATE SURVEY NO.
£ITY STATE ZIP
C.R. #
C I TY STATE
ZIP
PLANS
INSll~UCTIONS
LOCATION
UNDERGROUND
PIPES AND
JOINTS
TEST
DESCRIPTION
FLUSHING
TESTS
ACCEPIED BY APPR/~VING AUTHORIIY(~)NAM~o
ADDRESS !
INSTALLATION CONFORMS TO ACCEPTED PLANS
EQUIPMENT USED IS APPROVED
IF NO, STATE DEVIATIONS:
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION
OF CONTROL VALVES AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT
IF NO, EXPLAIN IN REMARKS SECTION
~YES NO
~'-~ES NO
HAVE COPIES OF APPROPRIATE INSTRUCTIONS AND CARE AND MAINTENANCE
CHARTS BEEN LEFT ON PREMISES
IF NO, EXPLAIN IN REMARKS SECTION
~YES NO
SUPPLIES BUILDINGS
PIPE TYPES AND CLASS
PIPE CONFORMS TO ~"~"---~ STANDARD
FITTINGS CONFORM TO ~ STANDARD
IF NO, EXPLAIN IN REMARKS SECTION
~S NO
JOINTS NEEDING ANCHORAGE CLAMPED,
ACCORDANCE WITH
IF NO, EXPLAIN IN REMARKS SECTION
TYPE JOINT
~w, YES __NO
~.ES
STRAPPED, OR BLOCKED
STANDARD
~ES __NO
FLUSHING. Flow the required rate until water is clear as indicated by no collection of foreign material
~p bags at outlets such as hydrants and blow-offs. Flush at flows not less than 400 GPM (1514
L/min) for 4-inch pipe, 600 GPM (2271 L/mn) for 5-inch pipe, 750 GPM (2839 L/min) for 6-inch pipe, 1000
GPM (3785 L/min) for 8-inch pipe, 1500 GPM {5678 L/min) for lO-inch pipe and 2000 GPM {7570 L/min) for
12-inch pipe. When supply cannot produce stipulated flow rates, obtain maximum available.
HYDROSTATIC. Hydrostatic test shall be made at not less than 200 psi (13.B bars) for two hours or 50 psi
{3.4 bars) above static pressure in excess of 150 psi (10.3 bars) for two hours.
LEAKAGE. New pipe laid with rubber gasketed joints shall, if the workmanship is satisfactory, have
~-iTi'T~-or no leakage at the joints. The amount of leakage at the joints shall not exceed 2 qts. per hr.
1.89 L/h) per 100 joints irrespective of pipe diameter. The leakage shall be distributed over all
lints. If such leakage occurs at a few joints the installation shall be considered unsatisfactory and
necessary repairs made. The amount of allowable leakage specified above may be increased by 1 fl oz
per in. valve diameter per hour (30 mL/25 mm/h) for each metal seated valve isolating the test section.
If dry barrel hydrants are tested with the main valve open, so the hydrants are under pressure, an ad-
ditional 5 oz per minute (150 mL/min) leakaDe is permitted for each hydrant.
NEW UNDERGROUND PIPING FLUSHED ACCORDING TO ~ STANDARD NO
BY (COMPANY)
IF no, EXPLAIN IN REMARKS SECTION
HOW FLUSHING FLOW WAS OBTAINED
PUBLIC WATER TANK OR RESERVOIR FIRE PUMP
LEAD-INS FLUSHED ACCORDING TO ~'-~
STANDARD
BY (COMPANY)
IF NO, EXPLAIN IN REMARKS SECTION
HOW FLUSHING FLOW WAS OBTAINED
~PUBLIC WATER TANK OR RESERVOIR FIRE PUMP
~ES --
ITHROUGH WHAT TYPE OPENING
HYDRANT BUTT ~PEN PIPE
~ES NO
THROUGH WHAT TYPE OPENING ~
Y CONN TO FLANGE & SPIGOT__ PEN PIPE
HYDROSTATIC
TEST
ALL NEW UNDERGROUND PIPING HYDROSTATICALLY TESTED AT
.~.~0 PSI FOR ~.~ HOURS
TOTAL AMOUNT OF LEAKAGE MEASURED
LEJ~FJ%GE GALS HOURS
TESTS
ALLOWABLE LEAKAGE
GALS HOURS ..~?,
NUMBER INSTALLED TYPE AND MAKE - ' ALL OPERATE SATISFACTORILY
HYDRANTS ~ YES NO
CONTROL
VALVES
PROCF_~MIRE
FOR
INSPECTIOM
AND
TESTING
TESTS
WITNESSED
BY:
~E
CE£TI FICTIOn(
WATER CONTROL VALVES LEFT WIDE OPEN ~YES __NO
IF NO, STATE REASON
HOSE THREADS OF FIRE DEPARTMENT CONNECTIONS AND HYDRANTS INTER-
CHANGEABLE WITH THOSE OF FIRE DEPARTMENT ANSWERING ALAKM ~-'YES NO
DATE LEFT IN SERVICE
Upon completion of work, inspection and tests shall be made by the contractor's representative witnessed by an owner's representa-
tive and local authority. All defects shall be corrected and system left in service before contractor's personnel leave the job.
A certificate shall be filled out and signed by ALL representatives. Copies shall be prepared for approving authorities, owners and
contractors. 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.
(Title) (Date)
PROPERTY OWNER (Signed) (oI~rIONAL)
LOCAL AUTHORITY (Sign ,- ,
1 CERTIFY THAT THE INFORMATIO '~(~N IS TRUE AND THAT THIS SPRINKLER SYSTEM WAS INSTALLED IN ACCORDANCE
WITH ARTICLE 5.43~3, TEXAS INSURANCE CODE AND THE RULES ADOPTED BY THE STATE BOARD OF INSURANCE.
--_ m (Print or Type~w-)
., ~ ll ll
R.M.E. LICENSE # ~'SL--Ot~l"~ DATE
ENG. FORM 100U