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'SIEMENS C NFPA 72 REPORT
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SYSTEM RECORD OF COMPLETION - ADDENDUM %;7171 Sits
System Name: Washington Square Mall Panel Name: Washington Square Mall
Date of Acceptance: 11 Nov 2022 Contract Info: OR1 P-FIS-WSQM LEVI'S
Supplemental Pages Attached: Yes
1. PROPERTY INFORMATION
Name of property: Washington Square Mall Levi's
Address: 9677 SW Washington Square RD C05 Tigard,Or 97223
Description of property:
Name of property representative: Washington Square Mall
Address: 9585 SW Washington Square RD Tigard,Or 97223
Phone: None Fax: None E-mail: None
2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION
Installation contractor: SIEMENS
Address: N/A
Phone: 971-207-1900 Fax: 971-207-1901 E-mail: NA
Service organization:
Address:_,
Phone:_ Fax:_ E-mail:
Testing organization: SIEMENS
Address: 9755 SW Barnes Rd,Suite 205, Portland,OR 97225
Phone: 503 2071900 Fax: 503 207 1901 E-mail: NA
Effective date for test and inspection contract:
Monitoring organization:
Address:
Phone:_ Fax:_ E-mail:
Account number:_ Phone line 1:_ Phone line 2:
Means of transmission:
Entity to which alarms are retransmitted: Phone:
3. DOCUMENTATION
On-site location of the required record documents and site-specific software: IN FACP ROOM/ON USB STICK
4. DESCRIPTION OF SYSTEM OR SERVICE
This is a: Modification Permit number: SEE PERMIT
NFPA 72 edition: NA
4.1 Control Unit
Manufacturer: Siemens Model number: XLS
Location: Security Office
4.2 Software and Firmware
Firmware revision number: ZEUS 14.04
4.3 Alarm Verification
E3 This system does not incorporate alarm verification.
Number of devices subject to alarm verification: NA Alarm verification set for NA seconds
• SIEMENS NFPA 72 REPORT
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5. SYSTEM POWER
5.1 Control Unit
5.1.1 Primary Power
Input voltage of control panel: 120 Control panel amps: 20
Overcurrent protection: Type: Breaker Amps: 20
Branch circuit disconnecting means location: In Electrical RM Number:
5.1.2 Secondary Power
Type of secondary power: Storage Battery
Location, if remote from the plant:
Calculated capacity of secondary power to drive the system:
In standby mode(hours): 24 In alarm mode(minutes): 15
5.2 Control Unit
Power extender panels are listed on the supplementary form Notification Appliance Power Panel Supplementary Record Of
Completion.
6. CIRCUITS AND PATHWAYS
Pathway Type Dual Media Pathway Separate Pathway Class Survivability Level
Signaling Line
Device Power
Initiating Device Level 0 Class B Level 0
Notification Appliance Level 0 Class B Level 0
7. REMOTE ANNUNCIATORS
Address Type Location
8. INITIATING DEVICES
Type Quantity Addressable or Conventional Alarm or Supervisory Sensing Technology
9. NOTIFICATION APPLIANCES
Type Quantity
STROBE 2
SPEAKER STROBE 6
10. SYSTEM CONTROL FUNCTIONS
Type Quantity
11. INTERCONNECTED SYSTEMS
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'SIEMENS NFPA 72 REPORT
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12. CERTIFICATION AND APPROVALS
12.1 System Installation Contractor
This Testing Was Performed in Accordance with Applicable NFPA Standards.
Sig Date:
Printed n- e: Grant Bahner
Organization: SIEMENS Title: SPECIALIST 2 Phone: 971-207-1900
12.2 System Operational Test
This system as specified herein has tested according to all NFPA standards cited herein.
Signe".. Date:
Printed na or: Grant Bahner
Organization: SIEMENS Title: SPECIALIST 2 Phone: 971-207-1900
12.3 Acceptance Test
Date and time of acceptance test: 02 Nov 2022 0600
Installing contractor representative: DAVID HEMMER
Testing contractor representative: Grant Bahner
Property representative:
AHJ representative: City of Tigard, Or