CERTIFICATION GIVEN: WHITE

Bellevue Fire Department

Fire Prevention Division
450 110th AVE NE
Bellevue, WA 98004
PH: 425.452.6872
FAX: 425.452.5287
www.bellevuewa.gov

SMOKE CONTROL SYSTEM

CONFIDENCE TEST REPORT
REF. BFDDS 11.09-8

YELLOW

Maintenance
Confidence Testing

SYSTEM _____ OF _____

ADDRESS

TIME IN:

NAME OF FACILITY

TIME OUT:

TYPE OF TEST:
OPERATIONAL

RED

DATE INSPECTED:
PERFORMANCE

QUARTERLY

SEMI ANNUAL

ANNUAL

PERIODIC TESTING OF SMOKE CONTROL SYSTEMS IN ACCORDANCE WITH BFDDS SECTION 11.09, INCLUDING OPERATIONAL TESTING,
SHALL BE PERFORMED BY QUALIFIED SERVICE TECHNICIANS WHO ARE FAMILIAR WITH THE PROPER OPERATION OF THE SMOKE CONTROL
SYSTEM AND EQUIPMENT. PERFORMANCE TESTING SHALL BE WITNESSED BY A SPECIAL INSPECTOR AND CONDUCTED BASED ON THE
ACCEPTANCE TEST PROCEDURE . THE INTENT OF THIS TESTING IS TO ENSURE THAT THE SYSTEM WILL FUNCTION AS DESIGNED DURING
AN EMERGENCY. CARE MUST BE EXERCISED TO AVOID CREATING CONDITIONS HARMFUL TO LIFE OR PROPERTY.

DOCUMENTATION

DOCUMENTATION IN FIRE COMMAND ROOM OR OTHER APPROVED LOCATION YES

YES

NO

NO

N/A

NO

N/A

N/A

APPROVED SMOKE CONTROL REPORT

IF YES, NOTE DATE OF REPORT:

OTHERWISE, EXPLAIN.

FINAL SPECIAL INSPECTION REPORT

IF YES, NOTE DATE OF REPORT:

OTHERWISE, EXPLAIN.

SYSTEM PLANS AND EVENT MATRIX

IF YES, NOTE DATE OF MATRIX:

OTHERWISE, EXPLAIN.

WEEKLY UUKL SELF-TEST RECORDS

IF YES, NOTE DATE RANGE:

OTHERWISE, EXPLAIN.

to

TESTING AND MAINTENANCE LOGS

IF YES, NOTE DATE RANGE:

OTHERWISE, EXPLAIN.

to

SYSTEM O&M DOCUMENTATION

SHAFT PRESSURIZATION

STAIR AND/OR ELEVATOR SHAFT PRESSURIZATION TESTS CONDUCTED? YES

LOWEST TEST
FLOOR/ZONE:

MIDDLE TEST
FLOOR/ZONE:

HIGHEST TEST
FLOOR/ZONE:

MINIMUM OBSERVED P
OF PRESSURIZED STAIR

MINIMUM OBSERVED P
OF PRESSURIZED STAIR

MINIMUM OBSERVED P
OF PRESSURIZED STAIR

MAXIMUM OBSERVED P
OF PRESSURIZED STAIR

MAXIMUM OBSERVED P
OF PRESSURIZED STAIR

MAXIMUM OBSERVED P
OF PRESSURIZED STAIR

DOOR OPENING
FORCES <30 LBS

YES /

NO

DOOR OPENING FORCES

<30 LBS

YES /

NO

DOOR OPENING FORCES

<30 LBS

MINIMUM OBSERVED P
OF PRESSURIZED ELEV

PRESSURIZED STAIR
ENCLOSURES TESTED

PRESSURIZED ELEVATOR
HOISTWAYS TESTED

MAXIMUM OBSERVED P
OF PRESSURIZED ELEV

DOOR OPENING FORCE

30 LBS

AUTOMATIC DOOR
OPERATION

AUTOMATIC DOOR
OPERATION

YES /

NO

AUTOMATIC DOOR
OPERATION

YES /

NO

AUTOMATIC DOOR
OPERATION

YES /

NO

YES /

NO

COMMENTS

FD - 404

Rev 10/2/07

PAGE 1

ZONE PRESSURIZATION

VERIFY OPERATION, ANNUNCIATION, AND MANUAL CONTROL OF ZONES YES

P TO FLOOR/ZONE ABOVE
HIGHEST TEST FLOOR/ZONE

P TO FLOOR/ZONE ABOVE
LOWEST TEST FLOOR/ZONE

HIGHEST TESTED
EVENT ZONE/FLOOR:

P TO FLOOR/ZONE BELOW
HIGHEST TEST FLOOR/ZONE

P TO FLOOR/ZONE BELOW
LOWEST TEST FLOOR/ZONE

MIDDLE TESTED
EVENT ZONE/FLOOR:

P TO FLOOR/ZONE ABOVE
MIDDLE TEST FLOOR/ZONE

LOWEST TESTED
EVENT ZONE/FLOOR:

P TO FLOOR/ZONE BELOW
MIDDLE TEST FLOOR/ZONE

PRESSURE TESTS
YES
CONDUCTED?

NO

N/A

EXHAUST / AIRFLOW
VELOCITY TESTS
YES
CONDUCTED?

NO

FANS AND DAMPERS

AIRFLOW TOWARD FIRE

YES
<200 FEET PER MINUTE

NO

N/A

FAN MAINTENANCE
YES
CURRENT?

NO

N/A

PROBLEMS FOUND :

N/A

NO

CORRECTIONS MADE: YES

NO

N/A

NO

N/A

NO

N/A

TOTAL NUMBER OF
DAMPERS INSPECTED

NO

N/A

MAINT. AND OPERATIONAL

PROGRAM FOLLOWED

YES

NO

COMMENTS:

FLOORS INSPECTED

YES

COMMENTS

NO

VERIFY OPERATION, ANNUNCIATION, AND MANUAL CONTROL OF EQUIPMENT YES

4-YEAR TESTING AND

YES
MAINTENANCE WORK?

N/A

COMMENTS:

VERIFY OPERATION, ANNUNCIATION, AND MANUAL CONTROL OF SYSTEM(S) YES

N/A

NO

YES
SATISFACTORY SYSTEM
PERFORMANCE

I HEREBY CERTIFY THAT THE FIRE PROTECTION SYSTEM LISTED ABOVE HAS BEEN PROPERLY TESTED AND INSPECTED FOR
RELIABILITY. ALL MAINTENENANCE, TESTING, INSPECTIONS, AND REPAIRS ARE CONSISTENT WITH THE INTERNATIONAL FIRE CODE AND NFPA STANDARDS.
DISCREPENCIES AND DEFICIENCIES HAVE BEEN REPORTED TO THE OWNER OR OWNERS REPRESENTATIVE FOR CORRECTIVE ACTION AND REPORTS FORWARDED TO THE BELLEVUE FIRE DEPARTMENT.
*********************THE SYSTEM ABOVE HAS BEEN RESTORED TO SERVICE AND IS FULLY OPERATIONAL

TECHNICIAN NAME :

PRINT NAME:

SIGN :

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