Information
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Site
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Postcode:
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Job Number Reference
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Walk Off by:
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Date of Walk Off:
Certificate of Conformity
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I declare that the work undertaken fully complies with the requirements of the Q-Mark Fire Stopping Installation scheme and that the work undertaken complies with Regulations 4 and 7 of the Building Regulations for England and Wales or in accordance with the local regulations in force at the specific job site location.
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Approved Installer Name - Andy Holland
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Approved Installer Number -
Fire Stopping
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Name of Client
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Name of Landlord
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Building Type
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Number of Floors
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Seal Category
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Number of holes made in concrete / brick
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Number of holes made in Fireboard / existing fire rated material
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Product in use
- Hilti CP 606 Firestop Acrylic Sealant
- FR Acrylic Intumescent Mastic / Protecta
- Other
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Details
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Product Batch Number
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Manufacture Date
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Expiry date
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Provide photograph
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Intended Fire Resistance Period if same system across installation. (If different, state hole number and Intended Fire Resistance Period)
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Any additional items of work / product used. Provide details
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Any existing untreated holes - provide details (location / floor )
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Provide photographs
Photographs
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Hole 1 - Floor / Location / Size (mm)
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Hole 2 - Floor / Location / Size (mm)
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Hole 3 - Floor / Location / Size (mm)
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Hole 4 - Floor / Location / Size (mm)
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Hole 5 - Floor / Location / Size (mm)
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Hole 6 - Floor / Location / Size (mm)
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Hole 7 - Floor / Location / Size (mm)
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Hole 8 - Floor / Location / Size (mm)
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Hole 9 - Floor / Location / Size (mm)
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Hole 10 - Floor / Location / Size (mm)
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Hole 12 - Floor / Location / Size (mm)
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Hole 20 - Floor / Location / Size (mm)
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Hole 21 - Floor / Location / Size (mm)
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Hole 22 - Floor / Location / Size (mm)
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Hole 40 - Floor / Location / Size (mm)
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Hole 42 - Floor / Location / Size (mm)
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Hole 60 - Floor / Location / Size (mm)
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Hole 61 - Floor / Location / Size (mm)
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Hole 80 - Floor / Location / Size (mm)
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Sign Off
Sign Off
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Additional Notes / Information
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Contractor Name
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Contractor Address
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Contractor Contact Details
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Operative
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Supervisor
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Completed Sign Off
