Attachment_6_Pre-Functional_Checklists.pdf
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- Dixie National Forest SO Construction Federal contract opportunity
- Solicitation number
- 1284N819R0002
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Text version
PRE-FUNCTIONAL CHECKLIST LOG
AS-1 Air separator 4/8/2019
BS-1 Branch selector box 4/8/2019
BS-2 Branch selector box 4/8/2019
BS-3 Branch selector box 4/8/2019
BS-4 Branch selector box 4/8/2019
CP-1 Domestic hot water circulation pump 4/8/2019
CS Communication Systems 4/29/2019
DX-1
Ductless mini-split AC unit (Indoor/Outdoor units) 4/8/2019
ERV-1 Energy recovery ventilator 4/8/2019
ET-1 Ground loop expansion tank 4/8/2019
FA Fire Alarm 4/29/2019
FC-1A Fan coil unit 4/8/2019
FC-1B Fan coil unit 4/8/2019
FC-2 Fan coil unit 4/8/2019
FC-3 Fan coil unit 4/8/2019
FC-4 Fan coil unit 4/8/2019
FC-5 Fan coil unit 4/8/2019
FC-6 Fan coil unit 4/8/2019
FC-7 Fan coil unit 4/8/2019
FC-8A Fan coil unit 4/8/2019
FC-8B Fan coil unit 4/8/2019
FC-9 Fan coil unit 4/8/2019
FC-10 Fan coil unit 4/8/2019
FC-11 Fan coil unit 4/8/2019
Remarks / Issues Equipment
ID
Current
Version Description Test Date Accepted
Project Title : Dixie NF Supervisor's Cedar City Rangers Office
SI Project No: J18-0043A
Rev. 4/29/2019 1 of 3
PRE-FUNCTIONAL CHECKLIST LOG
Remarks / Issues Equipment
ID
Current
Version Description Test Date Accepted
FC-12 Fan coil unit 4/8/2019
FC-13 Fan coil unit 4/8/2019
FC-14 Fan coil unit 4/8/2019
FC-15A Fan coil unit 4/8/2019
FC-15B Fan coil unit 4/8/2019
FC-16 Fan coil unit 4/8/2019
FC-17A Fan coil unit 4/8/2019
FC-17B Fan coil unit 4/8/2019
FC-18A Fan coil unit 4/8/2019
FC-18B Fan coil unit 4/8/2019
FC-19 Fan coil unit 4/8/2019
FC-20 Fan coil unit 4/8/2019
FC-21 Fan coil unit 4/8/2019
HR-1 Heat recovery unit (ground loop heat pump) 4/8/2019
HR-2 Heat recovery unit (ground loop heat pump) 4/8/2019
HVAC
Controls Digital control equipment 4/8/2019
LC Lighting Controls 4/29/2019
P-1 Ground loop circulation pump 4/8/2019
P-2 Ground loop circulation pump 4/8/2019
WH-1 Electric domestic water heater 4/8/2019
Project Title : Dixie NF Supervisor's Cedar City Rangers Office
SI Project No: J18-0043A
Rev. 4/29/2019 2 of 3
PRE-FUNCTIONAL CHECKLIST
EQUIPMENT ID:
PROJECT #: DESCRIPTION:
DATE CHECKLIST COMPLETED:
1. Submittals and Approvals
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Dorsett Technologies
Company Company
Date Date
Signature Signature
M. Troy Smalley
Printed Name Printed Name
SystematiCx
Company Company
Date Date
Approvals: This filled-out checklist has been reviewed. Its completion is approved with the exceptions noted.
Commissioning Authority(CxA) Owner's Representative (OR)
The above equipment and systems integral to them are complete and ready for functional testing. The checklist items are complete and have been checked off only by parties having direct knowledge of the event, respective to each responsible contractor. This Pre-Functional Performance Checklist is submitted for approval, subject to an attached list of outstanding items yet to be completed. A Statement of Correction will be submitted upon completion of any outstanding areas. None of the outstanding items preclude safe and reliable functional tests being performed.
General Contractor (GC) Mechanical Contractor (MC)
Electrical Contractor (EC) Test and Balance Contractor (TAB)
Temperature Controls Contractor (CC) Certified Start-up Technician (CST)
AS-1
J18-003A Air separator
LOCATION: 128 MECH
PROJECT: Dixie Supervisor's & Cedar City Rangers Office
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
SI Project #: J18-003A Forest Service
Rev. 4/8/2019 1 of 4 Equipment ID: AS-1
2. Documentation Verification
Responsible contractor (MC, EC, TAB, etc.) to verify each item and initial. Explain deficiencies in Notes section.
Y / N Contractor Initial Note #
3. Physical Installation and Inspection Checks
Responsible contractor (MC, EC, TAB, etc.) to verify each item and initial. Explain deficiencies in Notes section.
Y / N Contractor Initial Note #
All connections tight
Shut off valves / Isolation valves in place
Instrumentation installed according to specification
(thermometers, pressure gages, etc.)
Pumps Installed Correctly Per Air-separator Instructions
TAB
Installation of system and balancing devices allowed balancing to be completed following specified contract documents
Final
Startup report completed with this checklist attached
Safeties installed and safe operating ranges for this equipment provided to the commissioning agent
General Installation
Permanent labels affixed
Serial#:___________________
Manufacturer:______________
Model Number:_____________
Plumbing
Air Separator installed Correctly
Strainers in place and clean if needed
Air Vent attached
Equipment Installed Per Specifications for given trade
Drain / Hose bib attached per I.O.M.
Piping and Gaskets secure, no leaks
Pipe fittings complete & pipes properly supported
Pipes properly insulated
Manufacturer’s cut sheets
Performance data (pump curves, coil data, etc.)
Installation and startup manual and plan
Operation & Maintenance manuals
Check
Pre-functional checklist items are to be completed as part of startup & initial checkout, preparatory to functional testing.
· This checklist is not intended to take the place of the manufacturer’s recommended checkout and startup procedures or report.
· Items that do not apply shall be noted with the reasons on this form (N/A = not applicable, BO = by others).
· Contractors assigned responsibility for sections of the checklist shall be responsible to see that checklist items by their subcontractors are completed and checked off.
Check
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/8/2019 2 of 4 Equipment ID: AS-1
4. Notes Refer to Notes under individual line items.
Note #
END OF CHECKLIST
Description
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/8/2019 3 of 4 Equipment ID: AS-1
BLANK PAGE
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/8/2019 4 of 4 Equipment ID: AS-1
PROJECT #: DESCRIPTION:
DATE CHECKLIST COMPLETED:
1. Submittals and Approvals
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Dorsett Technologies
Company Company
Date Date
Signature Signature
M. Troy Smalley
Printed Name Printed Name
SystematiCx
Company Company
Date Date
Temperature Controls Contractor (CC) Certified Start-up Technician (CST)
Approvals: This filled-out checklist has been reviewed. Its completion is approved with the exceptions noted.
Commissioning Authority(CxA) Owner's Representative (OR)
The above equipment and systems integral to them are complete and ready for functional testing. The checklist items are complete and have been checked off only by parties having direct knowledge of the event, respective to each responsible contractor. This Pre-Functional Performance Checklist is submitted for approval, subject to an attached list of outstanding items yet to be completed. A Statement of Correction will be submitted upon completion of any outstanding areas. None of the outstanding items preclude safe and reliable functional tests being performed.
General Contractor (GC) Mechanical Contractor (MC)
Electrical Contractor (EC) Test and Balance Contractor (TAB)
BS-1
J18-003A Branch selector box
LOCATION: 107 CONF RM A
PROJECT: Dixie Supervisor's & Cedar City Rangers Office
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 1 of 4 Equipment ID:BS-1
Responsible contractor (MC, EC, TAB, etc.) to verify each item and initial. Explain deficiencies in Notes section.
Y / N Contractor Initial Note #
3. Physical Installation and Inspection Checks
Responsible contractor (MC, EC, TAB, etc.) to verify each item and initial. Explain deficiencies in Notes section.
Y / N Contractor Initial Note #
TAB
Installation of system and balancing devices allowed balancing to be completed following specified contract documents
Final
Startup report completed with this checklist attached
Safeties installed and safe operating ranges for this equipment provided to the commissioning agent
Serial #:____________________
Model #:_____________________
Manufacturer:_________________
Instrumentation installed according to mfr. specification
Electrical and Controls
Power disconnects in place and labeled
All electrical connections tight
Proper grounding installed for components and unit
Safeties in place and operable
All control devices and wiring complete
Check
General Installation
Permanent labels affixed
Vibration isolation equipment installed & released from shipping locks
Casing condition good: no dents or leaks
Piping Connections between Branch selector are tight and in good condition
Maintenance access acceptable for unit and components
Unit installed per manufacturer's recomendations
Sequences and control strategies
Pre-functional checklist items are to be completed as part of startup & initial checkout, preparatory to functional testing.
· This checklist is not intended to take the place of the manufacturer’s recommended checkout and startup procedures or report.
· Items that do not apply shall be noted with the reasons on this form (N/A = not applicable, BO = by others).
Operation & Maintenance manuals
Manufacturer’s cut sheets
Performance data (fan curves, coil data, etc.)
Installation and startup manual and plan
· Contractors assigned responsibility for sections of the checklist shall be responsible to see that checklist items by their subcontractors are completed and checked off.
Check
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 2 of 4 Equipment ID:BS-1
Note #
END OF CHECKLIST
Description
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 3 of 4 Equipment ID:BS-1
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 4 of 4 Equipment ID:BS-1
PROJECT #: DESCRIPTION:
DATE CHECKLIST COMPLETED:
1. Submittals and Approvals
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Dorsett Technologies
Company Company
Date Date
Signature Signature
M. Troy Smalley
Printed Name Printed Name
SystematiCx
Company Company
Date Date
Temperature Controls Contractor (CC) Certified Start-up Technician (CST)
Approvals: This filled-out checklist has been reviewed. Its completion is approved with the exceptions noted.
Commissioning Authority(CxA) Owner's Representative (OR)
The above equipment and systems integral to them are complete and ready for functional testing. The checklist items are complete and have been checked off only by parties having direct knowledge of the event, respective to each responsible contractor. This Pre-Functional Performance Checklist is submitted for approval, subject to an attached list of outstanding items yet to be completed. A Statement of Correction will be submitted upon completion of any outstanding areas. None of the outstanding items preclude safe and reliable functional tests being performed.
General Contractor (GC) Mechanical Contractor (MC)
Electrical Contractor (EC) Test and Balance Contractor (TAB)
BS-2
J18-003A Branch selector box
LOCATION: 113 FILES/STORAGE
PROJECT: Dixie Supervisor's & Cedar City Rangers Office
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 1 of 4 Equipment ID:BS-2
Responsible contractor (MC, EC, TAB, etc.) to verify each item and initial. Explain deficiencies in Notes section.
Y / N Contractor Initial Note #
3. Physical Installation and Inspection Checks
Responsible contractor (MC, EC, TAB, etc.) to verify each item and initial. Explain deficiencies in Notes section.
Y / N Contractor Initial Note #
TAB
Installation of system and balancing devices allowed balancing to be completed following specified contract documents
Final
Startup report completed with this checklist attached
Safeties installed and safe operating ranges for this equipment provided to the commissioning agent
Serial #:____________________
Model #:_____________________
Manufacturer:_________________
Instrumentation installed according to mfr. specification
Electrical and Controls
Power disconnects in place and labeled
All electrical connections tight
Proper grounding installed for components and unit
Safeties in place and operable
All control devices and wiring complete
Check
General Installation
Permanent labels affixed
Vibration isolation equipment installed & released from shipping locks
Casing condition good: no dents or leaks
Piping Connections between Branch selector are tight and in good condition
Maintenance access acceptable for unit and components
Unit installed per manufacturer's recomendations
Sequences and control strategies
Pre-functional checklist items are to be completed as part of startup & initial checkout, preparatory to functional testing.
· This checklist is not intended to take the place of the manufacturer’s recommended checkout and startup procedures or report.
· Items that do not apply shall be noted with the reasons on this form (N/A = not applicable, BO = by others).
Operation & Maintenance manuals
Manufacturer’s cut sheets
Performance data (fan curves, coil data, etc.)
Installation and startup manual and plan
· Contractors assigned responsibility for sections of the checklist shall be responsible to see that checklist items by their subcontractors are completed and checked off.
Check
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 2 of 4 Equipment ID:BS-2
Note #
END OF CHECKLIST
Description
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 3 of 4 Equipment ID:BS-2
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 4 of 4 Equipment ID:BS-2
PROJECT #: DESCRIPTION:
DATE CHECKLIST COMPLETED:
1. Submittals and Approvals
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Dorsett Technologies
Company Company
Date Date
Signature Signature
M. Troy Smalley
Printed Name Printed Name
SystematiCx
Company Company
Date Date
Temperature Controls Contractor (CC) Certified Start-up Technician (CST)
Approvals: This filled-out checklist has been reviewed. Its completion is approved with the exceptions noted.
Commissioning Authority(CxA) Owner's Representative (OR)
The above equipment and systems integral to them are complete and ready for functional testing. The checklist items are complete and have been checked off only by parties having direct knowledge of the event, respective to each responsible contractor. This Pre-Functional Performance Checklist is submitted for approval, subject to an attached list of outstanding items yet to be completed. A Statement of Correction will be submitted upon completion of any outstanding areas. None of the outstanding items preclude safe and reliable functional tests being performed.
General Contractor (GC) Mechanical Contractor (MC)
Electrical Contractor (EC) Test and Balance Contractor (TAB)
BS-3
J18-003A Branch selector box
LOCATION: 128 MECH
PROJECT: Dixie Supervisor's & Cedar City Rangers Office
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 1 of 4 Equipment ID:BS-3
Responsible contractor (MC, EC, TAB, etc.) to verify each item and initial. Explain deficiencies in Notes section.
Y / N Contractor Initial Note #
3. Physical Installation and Inspection Checks
Responsible contractor (MC, EC, TAB, etc.) to verify each item and initial. Explain deficiencies in Notes section.
Y / N Contractor Initial Note #
TAB
Installation of system and balancing devices allowed balancing to be completed following specified contract documents
Final
Startup report completed with this checklist attached
Safeties installed and safe operating ranges for this equipment provided to the commissioning agent
Serial #:____________________
Model #:_____________________
Manufacturer:_________________
Instrumentation installed according to mfr. specification
Electrical and Controls
Power disconnects in place and labeled
All electrical connections tight
Proper grounding installed for components and unit
Safeties in place and operable
All control devices and wiring complete
Check
General Installation
Permanent labels affixed
Vibration isolation equipment installed & released from shipping locks
Casing condition good: no dents or leaks
Piping Connections between Branch selector are tight and in good condition
Maintenance access acceptable for unit and components
Unit installed per manufacturer's recomendations
Sequences and control strategies
Pre-functional checklist items are to be completed as part of startup & initial checkout, preparatory to functional testing.
· This checklist is not intended to take the place of the manufacturer’s recommended checkout and startup procedures or report.
· Items that do not apply shall be noted with the reasons on this form (N/A = not applicable, BO = by others).
Operation & Maintenance manuals
Manufacturer’s cut sheets
Performance data (fan curves, coil data, etc.)
Installation and startup manual and plan
· Contractors assigned responsibility for sections of the checklist shall be responsible to see that checklist items by their subcontractors are completed and checked off.
Check
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 2 of 4 Equipment ID:BS-3
Note #
END OF CHECKLIST
Description
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 3 of 4 Equipment ID:BS-3
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 4 of 4 Equipment ID:BS-3
PROJECT #: DESCRIPTION:
DATE CHECKLIST COMPLETED:
1. Submittals and Approvals
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Dorsett Technologies
Company Company
Date Date
Signature Signature
M. Troy Smalley
Printed Name Printed Name
SystematiCx
Company Company
Date Date
BS-4
J18-003A Branch selector box
LOCATION: 142 OPEN OFFICE
PROJECT: Dixie Supervisor's & Cedar City Rangers Office
The above equipment and systems integral to them are complete and ready for functional testing. The checklist items are complete and have been checked off only by parties having direct knowledge of the event, respective to each responsible contractor. This Pre-Functional Performance Checklist is submitted for approval, subject to an attached list of outstanding items yet to be completed. A Statement of Correction will be submitted upon completion of any outstanding areas. None of the outstanding items preclude safe and reliable functional tests being performed.
General Contractor (GC) Mechanical Contractor (MC)
Electrical Contractor (EC) Test and Balance Contractor (TAB)
Temperature Controls Contractor (CC) Certified Start-up Technician (CST)
Approvals: This filled-out checklist has been reviewed. Its completion is approved with the exceptions noted.
Commissioning Authority(CxA) Owner's Representative (OR)
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 1 of 4 Equipment ID:BS-4
Responsible contractor (MC, EC, TAB, etc.) to verify each item and initial. Explain deficiencies in Notes section.
Y / N Contractor Initial Note #
3. Physical Installation and Inspection Checks
Responsible contractor (MC, EC, TAB, etc.) to verify each item and initial. Explain deficiencies in Notes section.
Y / N Contractor Initial Note #
Manufacturer’s cut sheets
Performance data (fan curves, coil data, etc.)
Installation and startup manual and plan
· Contractors assigned responsibility for sections of the checklist shall be responsible to see that checklist items by their subcontractors are completed and checked off.
Check
Sequences and control strategies
Pre-functional checklist items are to be completed as part of startup & initial checkout, preparatory to functional testing.
· This checklist is not intended to take the place of the manufacturer’s recommended checkout and startup procedures or report.
· Items that do not apply shall be noted with the reasons on this form (N/A = not applicable, BO = by others).
Operation & Maintenance manuals
Check
General Installation
Permanent labels affixed
Vibration isolation equipment installed & released from shipping locks
Casing condition good: no dents or leaks
Piping Connections between Branch selector are tight and in good condition
Maintenance access acceptable for unit and components
Unit installed per manufacturer's recomendations
Serial #:____________________
Model #:_____________________
Manufacturer:_________________
Instrumentation installed according to mfr. specification
Electrical and Controls
Power disconnects in place and labeled
All electrical connections tight
Proper grounding installed for components and unit
Safeties in place and operable
All control devices and wiring complete
TAB
Installation of system and balancing devices allowed balancing to be completed following specified contract documents
Final
Startup report completed with this checklist attached
Safeties installed and safe operating ranges for this equipment provided to the commissioning agent
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 2 of 4 Equipment ID:BS-4
Note #
END OF CHECKLIST
Description
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 3 of 4 Equipment ID:BS-4
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 4 of 4 Equipment ID:BS-4
PROJECT #: DESCRIPTION:
DATE CHECKLIST COMPLETED:
1. Submittals and Approvals
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
M. Troy Smalley
Printed Name Printed Name
SystematiCx
Company Company
Date Date
CP-1
J18-003A
Domestic hot water circulation pump.
LOCATION: 128 MECH
PROJECT: Dixie Supervisor's & Cedar City Rangers Office
The above equipment and systems integral to them are complete and ready for functional testing. The checklist items are complete and have been checked off only by parties having direct knowledge of the event, respective to each responsible contractor. This Pre-Functional Performance Checklist is submitted for approval, subject to an attached list of outstanding items yet to be completed. A Statement of Correction will be submitted upon completion of any outstanding areas. None of the outstanding items preclude safe and reliable functional tests being performed.
General Contractor (GC) Mechanical Contractor (MC)
Electrical Contractor (EC) Test and Balance Contractor (TAB)
Temperature Controls Contractor (CC) Certified Start-up Technician (CST)
Approvals: This filled-out checklist has been reviewed. Its completion is approved with the exceptions noted.
Commissioning Authority(CxA) Owner's Representative (OR)
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/8/2019 1 of 4 Equipment ID: CP-1
Responsible contractor (MC, EC, TAB, etc.) to verify each item and initial. Explain deficiencies in Notes section.
Y / N Contractor Initial Note #
3. Physical Installation and Inspection Checks
Responsible contractor (MC, EC, TAB, etc.) to verify each item and initial. Explain deficiencies in Notes section.
Y / N Contractor Initial Note #
Pre-functional checklist items are to be completed as part of startup & initial checkout, preparatory to functional testing.
· This checklist is not intended to take the place of the manufacturer’s recommended checkout and startup procedures or report.
· Items that do not apply shall be noted with the reasons on this form (N/A = not applicable, BO = by others).
Operation & Maintenance manuals
Manufacturer’s cut sheets
Performance data (pump curves, etc.)
Installation and startup manual and plan
· Contractors assigned responsibility for sections of the checklist shall be responsible to see that checklist items by their subcontractors are completed and checked off.
Check
Casing condition good: no dents or leaks, Piping Connections between Pumps, Valves are tight and in good condition
Maintenance access acceptable for unit and components
Unit installed per manufacturer's recomendations
Sequences and control strategies
Serial #:[____________________]
Model #: UP-15-18 B5/TLC [_____________________]
Manufacturer: Grundfos [_________________]
Instrumentation installed according to mnfg. specification
Electrical and Controls
Power disconnects in place and labeled
All electric connections tight
Proper grounding installed for components and unit
Safeties in place and operable
All control devices and wiring complete
Check
General Installation
Permanent labels affixed
Temperature Aqua Stat installed and operable
TAB
Installation of system and balancing devices allowed balancing to be completed following specified contract documents
Final
Startup report completed with this checklist attached
Safeties installed and safe operating ranges for this equipment provided to the commissioning agent
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/8/2019 2 of 4 Equipment ID: CP-1
Note #
END OF CHECKLIST
Description
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/8/2019 3 of 4 Equipment ID: CP-1
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/8/2019 4 of 4 Equipment ID: CP-1
PROJECT #: DESCRIPTION:
DATE CHECKLIST COMPLETED:
1. Submittals and Approvals
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Dorsett Technologies
Company Company
Date Date
Signature Signature
M. Troy Smalley
Printed Name Printed Name
SystematiCx
Company Company
Date Date
DX-1 (Indoor/Outdoor)
J18-003A Ductless mini-split
LOCATION: 126 TELECOM
PROJECT: Dixie Supervisor's & Cedar City Rangers Office
The above equipment and systems integral to them are complete and ready for functional testing. The checklist items are complete and have been checked off only by parties having direct knowledge of the event, respective to each responsible contractor. This Pre-Functional Performance Checklist is submitted for approval, subject to an attached list of outstanding items yet to be completed. A Statement of Correction will be submitted upon completion of any outstanding areas. None of the outstanding items preclude safe and reliable functional tests being performed.
General Contractor (GC) Mechanical Contractor (MC)
Electrical Contractor (EC) Test and Balance Contractor (TAB)
Temperature Controls Contractor (CC) Certified Start-up Technician (CST)
Approvals: This filled-out checklist has been reviewed. Its completion is approved with the exceptions noted.
Commissioning Authority(CxA) Owner's Representative (OR)
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 1 of 4 Equipment ID: DX-1
Check each item as verified and initial. Explain deficiencies under Notes.
Y / N Contractor Initial Notes
3. Physical Installation and Inspection Checks
Check each item as verified and initial. Explain deficiencies under Notes.
Y / N Contractor Initial Notes
Y / N Contractor Initial Notes
Pre-functional checklist items are to be completed as part of startup & initial checkout, preparatory to functional testing.
· This checklist is not intended to take the place of the manufacturer’s recommended checkout and startup procedures or report.
· Items that do not apply shall be noted with the reasons on this form (N/A = not applicable, BO = by others).
Operation & Maintenance manuals
Manufacturer’s cut sheets
Performance data (fan curves, coil data, etc.)
Installation and startup manual and plan
· Contractors assigned responsibility for sections of the checklist shall be responsible to see that checklist items by their subcontractors are completed and checked off.
Check
Check
General Installation
Permanent labels affixed
Indoor Unit to be mounted level
Sequences and control strategies
Instrumentation installed according to specification
Piping hooked up and properly connected
Vibration isolation equipment installed & released from shipping locks
Casing condition good: no dents or leaks
Maintenance access acceptable for unit and components
Clean up of equipment completed per contract documents
Low Ambient Control / Crank case Heater installed
Dryer installed
Piping insulation
Power disconnects in place and labeled
All electric connections tight
Proper grounding installed for components and unit
Safeties in place and operable
All control devices and wiring complete
Wind Baffle
Indoor unit condensate connection installed
Electrical and Controls
Check
Serial #:_________________
Model #:_________________
Manufacturer:______________
Final
Startup report completed with this checklist attached
Safeties installed and safe operating ranges for this equipment provided to the commissioning agent
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 2 of 4 Equipment ID: DX-1
Note
END OF CHECKLIST
Description
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 3 of 4 Equipment ID: DX-1
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 4 of 4 Equipment ID: DX-1
PROJECT #: DESCRIPTION:
DATE CHECKLIST COMPLETED:
1. Submittals and Approvals
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
M. Troy Smalley
Printed Name Printed Name
SystematiCx
Company Company
Date Date
Test and Balance Contractor (TAB)
Communication Systems Contractor (CSC) Certified Start-up Technician (CST)
CS
J18-003A Communication Systems
LOCATION:
Approvals: This filled-out checklist has been reviewed. Its completion is approved with the exceptions noted.
Commissioning Authority(CxA) Owner's Representative (OR)
The above equipment and systems integral to them are complete and ready for functional testing. The checklist items are complete and have been checked off only by parties having direct knowledge of the event, respective to each responsible contractor. This Pre-Functional Performance Checklist is submitted for approval, subject to an attached list of outstanding items yet to be completed. A Statement of Correction will be submitted upon completion of any outstanding areas. None of the outstanding items preclude safe and reliable functional tests being performed.
General Contractor (GC) Mechanical Contractor (MC)
Electrical Contractor (EC)
PROJECT: Dixie Supervisor's & Cedar City Rangers Office
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/29/2019 1 of 4 Equipment ID: CS
Check each item as verified and initial. Explain deficiencies under Notes.
Y/N Contractor Initial Note #
3. Physical Installation and Inspection Checks
Check each item as verified and initial. Explain deficiencies under Notes.
Y/N Contractor Initial Note #
Y/N Contractor Initial Note #
4. Testing and Operational Checks
Check each item as verified and initial. Explain deficiencies under Notes.
Y/N Contractor Initial Note #
Operation & Maintenance manuals
Check
Pre-functional checklist items are to be completed as part of startup & initial checkout, preparatory to functional testing.
· This checklist is not intended to take the place of the manufacturer’s recommended checkout and startup procedures or report.
· Items that do not apply shall be noted with the reasons on this form (N/A = not applicable, BO = by others).
Equipment is grounded per manufactures specifications
Shop drawings: Power, signal, and control wiring
Serial #:_________________________
Field quality - control reports
· Contractors assigned responsibility for sections of the checklist shall be responsible to see that checklist items by their subcontractors are completed and checked off.
Check
Manufacturer’s cut sheets
Installation Operation and startup manual
Control schematics and sequences
Electrical and Controls
Check
General Installation
Verify all field wiring test clear of short circuits.
Verify all field wiring test clear of earth grounds.
Final
Startup report completed with this checklist attached
All electric connections tight
Proper grounding installed for components and unit
System voltage readings are correct
All zones connected and operational - Energized
All Loud speakers installed and energized
Maintenance access acceptable
Installation of Panel is secured - All wiring and cables secured
Proper labeling of all units and controls
Model #:_________________________
Test and inspection reports completed
Manufacturer:______________________
Secure and support cables not exceeding 30"
Verify Cables not to be in contact with pipes ducts or other potentially dammaging items.
Perform operational Pre-testing so the system is free of noise and distortion
Check
General Installation
Physical condition acceptable, no visible dammage
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/29/2019 2 of 4 Equipment ID: CS
5. Notes Refer to Notes under individual line items.
Note #
END OF CHECKLIST
Description
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/29/2019 3 of 4 Equipment ID: CS
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/29/2019 4 of 4 Equipment ID: CS
PROJECT #: DESCRIPTION:
DATE CHECKLIST COMPLETED:
1. Submittals and Approvals
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Dorsett Technologies
Company Company
Date Date
Signature Signature
M. Troy Smalley
Printed Name Printed Name
SystematiCx
Company Company
Date Date
ERV-1
J18-003A Energy recovery ventilator
LOCATION: MECH 128
Approvals: This filled-out checklist has been reviewed. Its completion is approved with the exceptions noted.
Commissioning Authority(CxA) Owner's Representative (OR)
The above equipment and systems integral to them are complete and ready for functional testing. The checklist items are complete and have been checked off only by parties having direct knowledge of the event, respective to each responsible contractor. This Pre-Functional Performance Checklist is submitted for approval, subject to an attached list of outstanding items yet to be completed. A Statement of Correction will be submitted upon completion of any outstanding areas. None of the outstanding items preclude safe and reliable functional tests being performed.
General Contractor (GC) Mechanical Contractor (MC)
Electrical Contractor (EC) Test and Balance Contractor (TAB)
Temperature Controls Contractor (CC) Certified Start-up Technician (CST)
PROJECT: Dixie Supervisor's & Cedar City Rangers Office
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/8/2019 1 of 4 Equipment ID: ERV-1
Responsible contractor (MC, EC, TAB, etc.) to verify each item and initial. Explain deficiencies in Notes section.
Y / N Contractor Initial Note #
3. Physical Installation and Inspection Checks
Responsible contractor (MC, EC, TAB, etc.) to verify each item and initial. Explain deficiencies in Notes section.
Y / N Contractor Initial Note #
· Contractors assigned responsibility for sections of the checklist shall be responsible to see that checklist items by their subcontractors are completed and checked off.
Check
Manufacturer’s cut sheets
Performance data (fan curves, coil data, etc.)
Installation and startup manual and plan
Sequences and control strategies
Pre-functional checklist items are to be completed as part of startup & initial checkout, preparatory to functional testing.
· This checklist is not intended to take the place of the manufacturer’s recommended checkout and startup procedures or report.
· Items that do not apply shall be noted with the reasons on this form (N/A = not applicable, BO = by others).
Check
General Installation
Permanent labels affixed
Operation & Maintenance manuals
Serial #:_________________
Model#:_________________
Manufacturer:_____________
Final Filters Installed
Motor Voltage - Rated_________ Actual:_________
Motor Amps- Rated:_________ Actual:__________
Ducts (preliminary check)
Duct joint sealant properly installed
No apparent severe duct restrictions
Power disconnects in place and labeled
All electric connections tight
Proper grounding installed for components and unit
Safeties in place and operable
All control devices and wiring complete
Instrumentation installed according to specification
Vibration isolation equipment installed & released from shipping locks
Casing condition good: no dents or leaks, door gaskets installed
Maintenance access acceptable for unit and components
Clean up of equipment completed per contract documents
Duct connected into roof vent / Exhaust Louver
Duct cleaned as per specifications
Unit Duct Flex Connectons installed properly
Electrical and Controls
Spare belt present
All bearings and bushings greased to mfr. recommendations
Cooling inlet Sensors Installed properly
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/8/2019 2 of 4 Equipment ID: ERV-1
Y / N Contractor Initial Note #
4. Final Inspection
Check each item as verified and initial. Explain deficiencies under Notes.
Note #
END OF CHECKLIST
Check
Description
TAB
Installation of system and balancing devices allowed balancing to be completed following specified contract documents
Final
Startup report completed with this checklist attached
Safeties installed and safe operating ranges for this
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/8/2019 3 of 4 Equipment ID: ERV-1
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/8/2019 4 of 4 Equipment ID: ERV-1
PROJECT #: DESCRIPTION:
DATE CHECKLIST COMPLETED:
1. Submittals and Approvals
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Dorsett Technologies
Company Company
Date Date
Signature Signature
M. Troy Smalley
Printed Name Printed Name
SystematiCx
Company Company
Date Date
Electrical Contractor (EC) Test and Balance Contractor (TAB)
Temperature Controls Contractor (CC) Certified Start-up Technician (CST)
PROJECT: Dixie Supervisor's & Cedar City Rangers Office ET-1
J18-003A Expansion tank
LOCATION: 128 MECH
Approvals: This filled-out checklist has been reviewed. Its completion is approved with the exceptions noted.
Commissioning Authority(CxA) Owner's Representative (OR)
The above equipment and systems integral to them are complete and ready for functional testing. The checklist items are complete and have been checked off only by parties having direct knowledge of the event, respective to each responsible contractor. This Pre-Functional Performance Checklist is submitted for approval, subject to an attached list of outstanding items yet to be completed. A Statement of Correction will be submitted upon completion of any outstanding areas. None of the outstanding items preclude safe and reliable functional tests being performed.
General Contractor (GC) Mechanical Contractor (MC)
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 1 of 4 Equipment ID: ET-1
Responsible contractor (MC, EC, TAB, etc.) to verify each item and initial. Explain deficiencies in Notes section.
Y / N Contractor Initial Note #
3. Physical Installation and Inspection Checks
Responsible contractor (MC, EC, TAB, etc.) to verify each item and initial. Explain deficiencies in Notes section.
Y / N Contractor Initial Note #
TAB
Installation of system and balancing devices allowed balancing to be completed following specified contract documents
Balance reports supplied to Cx Agent
Final
Safeties installed and safe operating ranges for this equipment provided to the commissioning agent
Startup report completed with this checklist attached
Pipe fittings complete & pipes properly supported
Pipes properly insulated
All connections tight
Shut off valves / Isolation valves in place
Pumps Installed Correctly Per Manufactures Instructions
Pumps & Plumbing
Expansion tank installed correctly
Strainers in place and clean if needed
Air Vent attached
Equipment Installed Per Specifications for given trade
Pressure Gauges and Tank Purge Valve Installed
General Installation
Permanent labels affixed
Serial#:___________________
Manufacturer:______________
Model Number:_____________
Piping and Gaskets secure no leaks
Check
Manufacturer’s cut sheets
Installation and startup manual and plan
Operation & Maintenance manuals
System Balance Report
· Items that do not apply shall be noted with the reasons on this form (N/A = not applicable, BO = by others).
· Contractors assigned responsibility for sections of the checklist shall be responsible to see that checklist items by their subcontractors are completed and checked off.
Check
Pre-functional checklist items are to be completed as part of startup & initial checkout, preparatory to functional testing.
· This checklist is not intended to take the place of the manufacturer’s recommended checkout and startup procedures or report.
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 2 of 4 Equipment ID: ET-1
Note #
END OF CHECKLIST
Description
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 3 of 4 Equipment ID: ET-1
Project Title: Dixie NF Supervisor's Cedar City Rangers Office
Rev. 4/8/2019 4 of 4 Equipment ID: ET-1
PROJECT #: DESCRIPTION:
DATE CHECKLIST COMPLETED:
1. Submittals and Approvals
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Dorsett Technologies
Company Company
Date Date
Signature Signature
M. Troy Smalley
Printed Name Printed Name
SystematiCx
Company Company
Date Date
FC-1A
J18-003A Fan Coil Unit
LOCATION: 116 OPEN OFFICE (SOUTH)
Approvals: This filled-out checklist has been reviewed. Its completion is approved with the exceptions noted.
Commissioning Authority(CxA) Owner's Representative (OR)
The above equipment and systems integral to them are complete and ready for functional testing. The checklist items are complete and have been checked off only by parties having direct knowledge of the event, respective to each responsible contractor. This Pre-Functional Performance Checklist is submitted for approval, subject to an attached list of outstanding items yet to be completed. A Statement of Correction will be submitted upon completion of any outstanding areas. None of the outstanding items preclude safe and reliable functional tests being performed.
General Contractor (GC) Mechanical Contractor (MC)
Electrical Contractor (EC) Test and Balance Contractor (TAB)
Temperature Controls Contractor (CC) Certified Start-up Technician (CST)
PROJECT: Dixie Supervisor's & Cedar City Rangers Office
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/8/2019 1 of 4 Equipment ID: FC-1A
Responsible contractor (MC, EC, TAB, etc.) to verify each item and initial. Explain deficiencies in Notes section.
Y / N Contractor Initial Note #
3. Physical Installation and Inspection Checks
Responsible contractor (MC, EC, TAB, etc.) to verify each item and initial. Explain deficiencies in Notes section.
Y / N Contractor Initial Note #
· Contractors assigned responsibility for sections of the checklist shall be responsible to see that checklist items by their subcontractors are completed and checked off.
Check
Manufacturer’s cut sheets
Performance data (fan curves, coil data, etc.)
Installation and startup manual and plan
Sequences and control strategies
Pre-functional checklist items are to be completed as part of startup & initial checkout, preparatory to functional testing.
· This checklist is not intended to take the place of the manufacturer’s recommended checkout and startup procedures or report.
· Items that do not apply shall be noted with the reasons on this form (N/A = not applicable, BO = by others).
Check
General Installation
Permanent labels affixed
Operation & Maintenance manuals
Vibration isolation equipment installed & released from shipping locks
Casing condition good: no dents or leaks, Piping Connections are tight and in good condition
Maintenance access acceptable for unit and components
Unit installed per manufactures recomendations
Serial #:____________________
Model #:_____________________
Manufacturer:_________________
Instrumentation installed according to mnfg. specification
Coils / refrigerant lines attached per manufacturer's specifications
Condensate line attached and properly sloped to drain
Ducts (preliminary check)
Duct joint sealant properly installed
No apparent severe duct restrictions
Power disconnects in place and labeled
All electric connections tight
Proper grounding installed for components and unit
Safeties in place and operable
All control devices and wiring complete
Duct cleaned as per specifications
Unit Duct Flex Connections installed properly
Electrical and Controls
Motor Voltage - Rated:________Actual:________
Motor Amps - Rated:________ Actual:________
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/8/2019 2 of 4 Equipment ID: FC-1A
4. Notes Refer to Notes under individual line items.
Note #
Check
TAB
Installation of system and balancing devices allowed balancing to be completed following specified contract documents
Final
Startup report completed with this checklist attached
Safeties installed and safe operating ranges for this equipment provided to the commissioning agent
END OF CHECKLIST
Description
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/8/2019 3 of 4 Equipment ID: FC-1A
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/8/2019 4 of 4 Equipment ID: FC-1A
PROJECT #: DESCRIPTION:
DATE CHECKLIST COMPLETED:
1. Submittals and Approvals
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
Printed Name Printed Name
Company Company
Date Date
Signature Signature
M. Troy Smalley
Printed Name Printed Name
SystematiCx
Company Company
Date Date
Fire Alarm System
J18-003A
FACP, detectors, strobes/horns, etc.
LOCATION:
Approvals: This filled-out checklist has been reviewed. Its completion is approved with the exceptions noted.
Commissioning Authority(CxA) Owner's Representative (OR)
The above equipment and systems integral to them are complete and ready for functional testing. The checklist items are complete and have been checked off only by parties having direct knowledge of the event, respective to each responsible contractor. This Pre-Functional Performance Checklist is submitted for approval, subject to an attached list of outstanding items yet to be completed. A Statement of Correction will be submitted upon completion of any outstanding areas. None of the outstanding items preclude safe and reliable functional tests being performed.
General Contractor (GC) Fire Sprinkler Contractor (FSC)
Fire Alarm Contractor (FAC) Test and Balance Contractor (TAB)
Temperature Controls Contractor (CC) Certified Start-up Technician (CST)
PROJECT: Dixie Supervisor's & Cedar City Rangers Office
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/29/2019 1 of 4 Equipment ID: FA
Check each item as verified and initial. Explain deficiencies under Notes.
Y/N Contractor Initial Note#
3. Physical Installation and Inspection Checks
Check each item as verified and initial. Explain deficiencies under Notes.
Y/N Contractor Initial Note#
Pre-functional checklist items are to be completed as part of startup & initial checkout, preparatory to functional testing.
· This checklist is not intended to take the place of the manufacturer’s recommended checkout and startup procedures or report.
· Items that do not apply shall be noted with the reasons on this form (N/A = not applicable, BO = by others).
Operation & Maintenance manuals
Manufacturer:_____________________
Model #:________________________
· Contractors assigned responsibility for sections of the checklist shall be responsible to see that checklist items by their subcontractors are completed and checked off.
Check
Manufacturer’s cut sheets
Installation and startup manual and plan
Shop drawings, Wiring Diagrams, control schematics and sequences
Verify Fire Alarm signal initiations are intact and operable, manual station, smoke detectors, sprinkler system, heat detectors.
Manual Fire Alarm boxes are installed - Operational
System Smoke detectors are installed - Operational
Heat Detectors are installed - Operational
Strobe lights and devices if applicable - installed and operational
Prepare / Compile Testing reports
Fire alarm control unit is programmed and operational
Grounding of Fire alarm unit installed
Check
General Installation
Verify Secondary Power: 24-V DC supply system with batteries, automatic battery charger, and automatic transfer switch.
Batteries: Sealed lead calcium.
Audile alarm devices installed and operational
Include performance parameters and installation details for each detector, verifying that each detector is listed for complete range of air velocity, temperature, and humidity possible when air-handling system is operating.
Field quality control reports
Serial #:________________________
Record copy of site-specific software on CDROM and thumbdrive
Electrical Components, Devices, and Accessories: Listed and labeled
Project Title: Dixie NF Supervisor's and Cedar City Rangers Office
Rev. 4/29/2019 2 of 4 Equipment ID: FA
Y/N Contractor Initial Note#
4. Testing and Operational Checks
Check each item as verified and initial. Explain deficiencies under Notes.
Y/N Contractor Initial Note#
5. Notes Refer to Notes under individual line items.
Note #
Check
Solenoid control valves in place
Electrical and Controls
Sensors are properly calibrated
Check
General Installation
Verify all field wiring test clear of short circuits.
Verify all field wiring test clear of earth grounds.
Verify panel trouble, supervisory, and alarm conditions
Sensors are properly calibrated
System voltage readings are correct
Verify all required I/O points function from the AlarmControll center
Final
Startup report completed with this checklist attached
Prepare / Compile Testing reports / Fire alarm system will be considered defective if it does not pass test and inspections
Power…
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