Fillable Form 1: Fire Alarm System Certification Form (Office of Innovation and Technology)

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Form 1: Fire Alarm System Certification Form (Office of Innovation and Technology)

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***DO NOT MAIL THIS FORM***
Page 1 of 5
TP_009_F Fire Alarm System Certification Form
Fire Alarm System Certification Form
Use this form to provide results and certify the fire alarm system testing performed. Submit one certification for each system.
2
1
3
Indicate Type of Certification (check one): ☐ New installation* ☐ Annual **
Address: ___________________________________________________________________________________
Name: _____________________________________________________________________________________
Address: ___________________________________________________________________________________
Email: _______________________________________________ Phone: ______________________________
Building Owner/Owner’s
Agent
Provide the contact information for
the building owner/owner’s agent.
Property Information
Provide the property address
where the testing will be
performed.
Contractor and Inspector
Information
(a) The contractor must provide
their contact information and
license number, then sign and
date.
(b) The fire alarm inspector must
p
rovide their contract
information as well as license
and certification numbers.
(a) Contractor Information
Contractor Name: ________________________________ Contractor License #: __________________
Email: _________________________________________ Phone: _____________________________
Contractor Signature: ________________________________________ Date: ____________________
(b) Fire Alarm Inspector Information
Fire Alarm Inspector Name: _____________________________________________________________
Email: _________________________________________ Phone: _____________________________
Fire Alarm Inspector License #: ______________________ Certification #: _______________________
General Information
Note: Skip section 4 for new
installation.
This section is to be completed by
the property owner or agent.
P
rovide explanation for all “no”
answers, except as noted.
4
• Is the building occupied?
☐
Yes
☐
No
• Has the building occupancy or hazard or floor layout changed since the last inspection? ☐Yes ☐No
o If yes, explain: _________________________________________________________________________
• Are all systems kept in service? ☐Yes ☐No
• Are the test results kept on file? ☐Yes ☐No
• Has there been any modifications to the system since the last certification? ☐Yes ☐No
o I
f yes, explain: ______________________________________________________________________________
• Was there any action of alarm since the last certification
? ☐
Yes ☐No
o If yes, explain: ______________________________________________________________________________
• Does this certification cover all fire alarm systems in the building? ☐Yes ☐No
This section is to be completed by
the fire alarm inspector.
5
• Is the fire alarm Control Panel in an accessible location(in main entrance or unlocked room)?
☐
Yes
☐
No
• Is the battery charging circuit in the Control Panel operating correctly / at the proper voltage? ☐Yes ☐No
• Is Ground Fault Monitoring testing satisfactory? ☐Yes ☐No
• Is the test of lamps and LED’s in the Control Panel satisfactory? ☐Yes ☐No
• Is the test of interface equipment satisfactory? ☐Yes ☐No
• Are the audible and visible trouble and alarm signals in the Control Panel satisfactory? ☐Yes ☐No
• Are trouble signal silence switches and alarm silence switches in the Control Panel
tested satisfactory? ☐Yes ☐No
• Is the off-premises transmission test satisfactory? ☐Yes ☐No
• Is the remote annunciator test satisfactory? ☐Yes ☐No
• Is the Control Panel supervision test acceptable? ☐Yes ☐No
*Upload completed forms to the Building Permit in eCLIPSE.
**Upload completed forms through the “Submit an Annual
Certification Report” option in eCLIPSE. www.eclipse.phila.gov.
***DO NOT MAIL THIS FORM***
Page 2 of 5
TP_009_F Fire Alarm System Certification Form
6
Initiating Devices
Section (A)
*Note: The certification of smoke
detector sensitivity shall be
performed according to the
Philadelphia Fire Code Section
907.
F-907: Alternate year sensitivity
testing shall begin in odd-
numbered years. Where the
one-year sensitivity test occurs
in an even-numbered year, the
next sensitivity test is not due
until the second subsequent
odd-numbered year.
Results of sensitivity tests shall
be listed on page 4 of this form or
an NFPA compliant panel printout
shall be provided for each year
testing is performed.
Complete Sections (B) and
(C) only if applicable.
(A) Initiating Devices
• Are signs mounted at each pull station stating:
“IN CASE OF FIRE: SOUND ALARM AND CALL 911 or THE FIRE DEPARTMENT”? ☐Yes ☐No
• Are the manual fire alarm box tests acceptable? ☐Yes ☐No
• Are the smoke detector inspection / tests acceptable? ☐Yes ☐No
• Are the smoke detector thermal elements tests acceptable? ☐Yes ☐No
• Are the smoke detector control output tests acceptable? ☐Yes ☐No
• Are non-restorable heat detectors inspected and in satisfactory condition? ☐Yes ☐No
• Are restorable heat detector tests acceptable? ☐Yes ☐No
• Are the alarm verification tests satisfactory? ☐Yes ☐No
• Are the duct smoke detector tests acceptable? ☐Yes ☐No
• *Is the sensitivity of all Smoke Detectors tested in accordance with NFPA 72 (2016)
Section 14.4.4.3.4? ☐Yes ☐No
(B) Sprinkler System Supervision (complete if applicable) ☐Yes ☐No
If no, explain: ____________________________________________________________________________________
• Are the water flow switch inspection / tests acceptable? ☐Yes ☐No
• Are the valve tamper switch inspection / tests acceptable? ☐Yes ☐No
• Are the low temperature sensor inspection / tests acceptable? ☐Yes ☐No
• Are low air pressure switch inspection / tests acceptable? ☐Yes ☐No
• Are the Fire Pump power supervision inspection / tests acceptable? ☐Yes ☐No
• Are the Fire Pump Running supervision inspection / tests acceptable? ☐Yes ☐No
• Are the Fire Pump Trouble supervision inspection / tests acceptable? ☐Yes ☐No
• Are Fire Pump Alternate Power inspection / tests acceptable? ☐Yes ☐No
(C) Other Initiation (complete if applicable) ☐Yes ☐No
• Are all range hood / other suppression systems interconnected to this system as required? ☐Yes ☐No
• Are all range hood / other suppression systems inspections / tests acceptable? ☐Yes ☐No
• Are all existing air handler duct smoke detectors interconnected to this system? ☐Yes ☐No
• Were all air handler duct smoke detector inspection / tests acceptable? ☐ Yes ☐ No
7
Section (A)
Complete the table on page 3 to
record the ambient and alarm
sound level tests.
(Continue on next page)
(A) AUDIBLE / VISIBLE DEVICES
• Are the ambient sound levels tested with the normal ambient noises present (HVAC, etc.)?
and recorded on Page 3? ☐Yes ☐No
• Are alarm sound levels tested and recorded on Page 3? ☐Yes ☐No
• Are visible alarms tested and operating properly? ☐Yes ☐No
• Did sound levels reach the minimum requirement noted below? ☐Yes ☐No
(check the appropriate box below)
☐ Systems installed prior to January 1984 = Sufficient volume to be heard
☐ January 1984 until March 1991 = 15 dba above ambient in occupied spaces
☐ May 1991 until December 2009 = 70 dba in sleeping rooms, 70 mechanical spaces, 60 in remaining spaces
☐ January 2010 until Present = 75 dba sleeping rooms, 70 in mechanical spaces and 60 in remaining spaces
***DO NOT MAIL THIS FORM***
Page 3 of 5
TP_009_F Fire Alarm System Certification Form
7
LOCATION TESTED (Fill in exact location next to description, i.e., Unit D-10 etc.)
FLOOR
AMBIENT
LEVEL
ALARM
LEVEL
COMMON AREA LOCATION:
COMMON AREA LOCATION:
COMMON AREA LOCATION:
SLEEPING AREA:
SLEEPING AREA:
SLEEPING AREA:
SLEEPING AREA:
SLEEPING AREA:
OTHER:
OTHER:
OTHER:
OTHER:
(continued)
Audibility record: Describe in
detail the locations tested and the
results in the table.
Audible readings must be taken in
at least one unit per floor AND at
least one reading for each style
unit in the building.
Use additional sheets if
necessary.
Complete Section (B) if
applicable.
(B) OTHER SYSTEM OUTPUTS / INTERCONNECTIONS (complete if applicable)
☐
Yes
☐
No
• If no, explain: ___________________________________________________________________________________
• Are all range hood / other suppression systems interconnected to fuel shut off / power
disconnects as required? ☐Yes ☐No
• Are all air handlers over 2000 cfm shut down as required? ☐Yes ☐No
• Are all Primary Floor Elevator Recall inspection / tests acceptable? ☐Yes ☐No
• Are all Secondary Floor Elevator Recall inspection / tests acceptable? ☐Yes ☐No
• Are all Elevator Power Shutoff / Shunt Trip inspection / tests acceptable? ☐Yes ☐No
• Are all Elevator Fire Fighters Hat feature inspection / tests acceptable? ☐Yes ☐No
• Are all Door Hold Open Release inspection / tests acceptable? ☐Yes ☐No
• Is the fire alarm system power connected to a branch circuit of house panel?
☐
Yes
☐
No
• Is the fire alarm system power disconnected for the dedicated branch circuit locked
in the “On” position? ☐Yes ☐No
• Is the fire alarm system power disconnect location clearly identified in writing at or on
the control panel? ☐Yes ☐No
• Is the test of the primary power source satisfactory? ☐Yes ☐No
• Is the test of the secondary power source (e.g., batteries) satisfactory? ☐Yes ☐No
• Is the system tested using the secondary power source? ☐Yes ☐No
• Are all additional NAC power supply inspection / tests acceptable? ☐Yes ☐No
• Are all additional sub control, amplifier, firefighter phone panels and auxiliary power
supply inspection / tests acceptable? ☐Yes ☐No
• Are all batteries for additional NAC power supplies sub controls, amplifiers, fire fighter
phone panels and auxiliary, power supplies load tests / inspections acceptable? ☐Yes ☐No
• Are all batteries load tested? ☐Yes ☐No
• Provide Make and Model of tester used: ______________________________________________________________
Electrical
8
***DO NOT MAIL THIS FORM***
Page 4 of 5
TP_009_F Fire Alarm System Certification Form
9
Voice, Phone,
Monitoring
Complete Sections (A),
(B) and (C) if applicable.
(A) VOICE EVACUATION SYSTEM (complete if applicable):
☐
Yes
☐
No
If no, explain: ___________________________________________________________________________________
• Is this system applicable to the system being tested? ☐Yes ☐No
If yes, complete this section:
• Is the Fire Command Center operating properly? ☐Yes ☐No
• Is speaker sound pressure and clarity recorded in the Section 7 table? ☐Yes ☐No
• Are amplifier / tone generators test satisfactory? ☐Yes ☐No
(B)
FIRE FIGHTER PHONE SYSTEM (complete if applicable): ☐Yes ☐No
If no, explain:____________________________________________________________________________________
• Is the call-in signal silence function correct? ☐Yes ☐No
• Is the off-hook indicator verified? ☐Yes ☐No
• Are phone jacks tested satisfactorily? ☐Yes ☐No
• Are phone sets tested satisfactorily? ☐Yes ☐No
• Are handset system voice quality and clarify acceptable? ☐Yes ☐No
(C)
MONITORING (complete if applicable): ☐Yes ☐No
If no, explain: ____________________________________________________________________________________
• Is this system monitored or required to be monitored? ☐Yes ☐No
If yes, complete this section:
• This system is monitored under which of the NFPA 72 monitoring categories?
☐ Proprietary Supervising Station ☐ Central Station Service
☐ Remote Supervising Station ☐ Other, explain: ________________________________________
• The system is monitored in compliance with the selected method above. ☐Yes ☐No
• The system sends a daily test signal to the monitoring station. ☐Yes ☐No
• The system has two telephone lines or other NFPA method of communication
with the monitoring station. ☐Yes ☐No
• The monitoring station is UL approved to receive Fire Alarm Signals. ☐Yes ☐No
The name of the Monitoring Entity is: _____________________________________________
Phone #: _________________________________
Account Reference No.:______________________ UL Certification #: __________________________
• The system is tested to the monitoring station for the following conditions:
Alarm and Restore ☐Yes ☐No
Trouble and Trouble Restore ☐Yes ☐No
Ground Fault and Restore ☐Yes ☐No
Supervisory Signal and Restore ☐Yes ☐No
AC Power Loss and Restore ☐Yes ☐No
***DO NOT MAIL THIS FORM***
Page 5 of 5
TP_009_F Fire Alarm System Certification Form
Declaration & Signature
By accepting this statement, I, the certified technician shown on this form, certify that this fire alarm system(s) has been properly inspected for functional operation in
accordance with the current Fire Code (FC) used by the department that has jurisdiction and NFPA Standards adopted by the FC for this system. Any deficiencies found
are noted in the report and have been reported to the building owner/owner’s agent for corrective action.
The certification must be presented by the Contractor to the building owner/owner’s agent upon completion and shall be maintained on the property and made available
for inspection upon request.
The Deficiency Form (TP_015_F) shall be submitted to the Department of Licenses and Inspections when deficiencies are not corrected within 45 days.
Signature of Fire Alarm Inspector: ______________________________________________________ Date: _________________________
Signature of Building Owner/Owner’s Agent: _____________________________________________ Date: _________________________
DETECTOR SENSITIVITY RESULTS
LOCATION
DEVICE
TYPE
VISUAL
CHECK
FUNCTIONAL
TEST
FACTORY
SETTING
MEASURED
SETTING
PASS
FAIL
10
Additional
Explanations and
Notes
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________
________________________
_____________________________________________________________________
_
______________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
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Form 1: Fire Alarm System Certification Form (Office of Innovation and Technology)

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Completed 24 November 2021

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