Form Cms-2786v - Fire Safety Survey Report - Icf-Iid (Small Facilities) 2012 Life Safety Code Page 15
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41Name of Facility
2012 LIFE SAFETY CODE
PART II – EXISTING RESIDENT BOARD & CARE OCCUPANCIES
MET
NOT
N/A
REMARKS
ID
MET
PREFIX
(PROMPT EVACUATION)
K353
11. A representative sample of dry pendant sprinklers are tested at 10
years (NFPA 25, section 5.3.1.1.15).
12. Antifreeze solutions are tested annually (NFPA 25, section 5.3.4).
13. Control valves are operated through their full range and returned to
normal annually (NFPA 25, section 13.3.3.1).
14. Operating stems of OS&Y valves are lubricated annually (NFPA 25,
section 13.3.4).
15. Dry pipe systems extending into unheated portions of the building are
inspected, tested and maintained (NFPA 25, section 13.4.4).
A. Date sprinkler system last checked and necessary maintenance
provided. __________________________
B. Show who provided the service. _________________________
C. Note the source of the water supply for the automatic sprinkler system.
__________________________________
(Provide in REMARKS information on coverage for any non-required or
partial automatic sprinkler system.)
33.2.3.5.3, 33.2.3.5.8, 9.7.5, 9.7.7, 9.7.8, and NFPA 25
K354
Sprinkler System – Out of Service
Where a required automatic sprinkler system is out of service for more
than 10 hours in a 24-hour period, the authority having jurisdiction shall
be notified, and the building shall be evacuated or an approved fire
watch system be provided for all parties left unprotected by the
shutdown until the sprinkler system has been returned to service.
33.2.3.5.3, 9.7.6.1, 15.5.2 (NFPA 25)
Form CMS-2786V (10/2016)
Page
15
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