HomeMy WebLinkAboutB14-0240_B14-0240 Med Gas Cert. - 201 202_1421191800.pdf Department of Community Development
75 South Frontage Road
TOWN OF VAIL ' Vail, CO 81657
Tel: 970.479.2128
www.vailgov.com
Development Review Coordinator
TRANSMITTAL FORM
Use this form when submitting additional information for planning applications or building permits.
This form is also used for requesting a revision to building permits. A two hour minimum building review
fee of$110 will be charged upon reissuance of the permit.
Application/Permit#(s) information applies
to: Attention: 0 Revisions
B-14-0240 Martin Haeberle b Response to Correction Letter
n attached copy of correction letter
o�Deferred Submittal
R J Other Med Gas Cert.-Rooms 201/202
Project Street Address:
181 W. Meadow Dr.
(Number) (Street) (Suite#)
Building/Complex Name: Vail Valley Medical Center Description of Transmittal/List of Changes, Items Attached:
Med Gas Certification - Rooms 201 /202
Applicant Information
(architect, contractor, owner/owner's rep)
Contact Name: Haselden Construction
Address: 6950 S. Potomac St.
City Centennial State: CO Zip: 80112
Contact Name: Nick Rubino
(use additional sheet if necessary)
Contact Phone: 720-398-7831
Building Permits:
haselden.com Revised ADDITIONAL Valuations (Labor&Materials)
nickrubino
Contact E-Mail: @ (DO NOT include original valuation)
I hereby acknowledge that I have read this application,filled out Building: $
in full the information required,completed an accurate plot plan,
and state that all the information as required is correct. I agree to Plumbing: $
comply with the information and plot plan, to comply with all Town
ordinances and state laws, and to build this structure according Electrical: $
to the town's zoning and subdivision codes, design review ap-
proved, International Building and Residential Codes and other Mechanical: $
ordinances of the Town applicable thereto.
o,N�,e��r�s9�adek��R�e�o Total: $0
X Nick Rubino o-�a=a�da�oa=�a�®�a��°MakR�e,o
Owner/Owner's Representative Signature(Required)
Date Received:
For Office Use Only:
Fee Paid:
Received From:
Cash Check#
CC: Visa/MC Last 4 CC# exp. date:
Authorization #
MEDICO.
I 1370 Halan Street
Lakewood CO 50214
PhoneFax 30330-32-7297-97-2134r
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AIR TES71N6 \ A /SERVIIES , INC . ..—..—.-
MEDICAL
NC . --..—.MEDICAL GAS SYSTEMS JOBSITE VISIT_&INSTALLER AFFIDAVIT FORM PER NFPA: Ni1999 0 2002
r, I1AKb ❑2005 ❑ 2012
11Facility: OL V4( C.6aCIL
Address:
Job Description: „ S 0 1 2.0Z
-
Contractor: 11 G ilLa vlf _l. Date: 1— !3—/-3”
J L of Medical Air Testing&Services,Inc.has tested the following equipment for proper operation per NFPA 99
Oxygen Outlets4
WAGD Inlets Vacuum Pump System
Vacuum Inlets Area Alarm Panels Air Compressor System
Medical Air Outlets d Master Alarm Panels Proportioning System
Nitrogen Outlets Zone Valves Dental Vacuum Pump
L Nitrous Oxide Outlets Manifolds Dental Air Compressor
(3 Carbon Dioxide Outlets Bulk Gas Systems J Other: �C
Comments: A u 11-)6g_. i.�5 ._ A15 KJ _ 7 it-rit � I Use-
NFPA 99 requires several criteria be met on behalf of the installer prior to a 3rd party verification for any medical gas system modification,
replacement, remodel, addition,or new installation that will be placed into service for patient use. Since a representative from our company
was not present throughout the entire course of the installation,it is necessary to have the installer's authorized agent complete and sign this
affidavit. I, the undersigned, do hereby declare the he following procedures and requirements have been successfully completed by the
contractor/installer to satisfy the minimum requirements set forth by NFPA 99 for medical gas system pipeline installations(unless otherwise
noted):
• The contractor/installer used required materials and practiced compliant storage/handling techniques
• The contractor/installer maintains required brazer/installer qualification credentials
• The contractor/installer used required techniques for pipeline component preparation and installation
• The contractor/installer properly labeled all required components of the medical gas system
• The contractor/installer successfully completed the Initial Piping Blow Down using oil-free,dry nitrogen NF
• The contractor/installer successfully completed Initial Pressure Test using oil-free, dry nitrogen NF at 1.5 times the system working
pressure,but not less than 150 psi (1035 kPa)for Positive Pressure Medical Gas Piping and 60 psi for Vacuum Piping(415 kpa)
• The contractor/installer successfully completed Initial Cross-Connection Test using oil-free,dry nitrogen NF at 50 psi(345 kPa)
• The contractor/installer successfully completed Initial Piping Purge Test using oil-free,dry nitrogen NF
• The contractor/installer successfully completed 24-hr Standing Pressure Test for Positive Pressure Medical Gas Piping using oil-free,
dry nitrogen NF at 20%above normal system operating line pressure
• The contractor/installer successfully completed 24-hr Standing Vacuum Test for Vacuum Piping using oil-free, dry nitrogen NF
between 12 in.(300 mm)and full vacuum
syste s)were verified for compliance with NFPA 99 as a Level/Category 1 2 3 4 Other:
System(s)meet the minimum NFPA Healthcare Facilities Standard to which the facility was tested.
Does not meet the minimum NFPA Healthcare Facilities Standard to which the facility was tested, unless accepted by the
Authority Having Jurisdiction(Note: NFPA 99 states that"An existing system that is not in strict compliance with the provisions of
the standard shall be permitted to be continued in use as long as the authority having jurisdiction has determined that such use
does not constitute a distinct hazard to life.")
ical
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responsibility ty of the hospital Ito inforif m all personnelred. The of system m status.Thistion of any system awas ins installed andlver verified in compliance thof the sNiFPA 991by he
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Installer ASSE 6010 Installer# _ J Not Available 1
�`.. - • 'ty Authorized Representative Position/Job Title L eK g/Nii4G Tec,/,, Not Available
SIM �. Medical Air Testing&Services,Inc. ASSE 6030 Verifier#Qo1 f Z 95' Not Available
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