Form Cms-2786v - Fire Safety Survey Report - Icf-Iid (Small Facilities) 2012 Life Safety Code Page 34
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41Name of Facility
2012 LIFE SAFETY CODE
ID
NOT
PART III– NEW RESIDENTIAL BOARD & CARE OCCUPANCIES
MET
N/A
REMARKS
MET
PREFIX
K353
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).
Date sprinkler system last checked and necessary maintenance provided.
__________________________
Show who provided the service. _________________________
Note the source of the water supply for the automatic sprinkler system.
__________________________________
32.2.3.5.3, 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.
32.2.3.5.3, 9.7.6.1, 15.5.2 (NFPA 25)
Form CMS-2786V (10/2016)
Page
34
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