The URL can be used to link to this page

Permit Support Document (39) SYSTEM RECORD OF COMPLETION (continued) 9. NOTIFICATION APPLIANCES Type Quantity Description Audible N/A N/A Visible 72+1 STROBE-ONLY Combination Audible and Visible 42+2 HORN-STROBE 10. SYSTEM CONTROL FUNCTIONS Type Quantity Hold-Open Door Releasing Devices N/A HVAC Shutdown N/A Fire/Smoke Dampers N/A Door Unlocking N/A Elevator Recall N/A Elevator Shunt Trip N/A N/A N/A 11. INTERCONNECTED SYSTEMS O This system does not have interconnected systems. ❑ Interconnected systems are listed on supplementary sheet N/A . 12. CERTIFICATION AND APPROVALS 12.1 System Installation Contractor This system as specified herein has been installed according to all NFPA standards cited herein. Signed: NATHAN BUTZ Printed name: NATHAN BUTZ Date: 06/28/2023 Organization:GB MANCHESTER INC Title: PROJECT MANAGER Phone: 360-816-0484 12.2 System Operational Test This system as specified herein has tested according to all NFPA standards cited herein. Signed: NATHAN BUTZ Printed name: NATHAN BUTZ Date: 06/28/2023 Organization:GB MANCHESTER INC Title: PROJECT MANAGER Phone:360-816-0484 12.3 Acceptance Test Date and time of acceptance test: 06/28/2023 8am Installing contractor representative: NATHAN BUTZ,GB MANCHESTER INC. Testing contractor representative: NATHAN BUTZ,GB MANCHESTER INC. Property representative: (not present) AHJ representative: NFPA 72(p.3 of3) `��rw ®2016 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution.No other reproduction or transmission in any form permitted without written permission of NFPA.For inquiries or to report unauthorized NF use,contact licensing@nfpa.org. NOTIFICATION APPLIANCE POWER PANEL SUPPLEMENTARY RECORD OF COMPLETION Form Completion Date: 06/28/2023 Number of Supplemental Pages Attached: 1 1. PROPERTY INFORMATION (sheet included for future use) Name of property: Costco Tgard Address: 7850 SW Darmouth St Tigard OR 97223 2. NOTIFICATION APPLIANCE POWER EXTENDER PANELS Make and Model Loeatipn Area Served Power Source Firelite FCPS-24FS8(NAC1) Existing Existing Existing Firelite FCPS-24FS8(NAC2) Existing Existing+scope of this permit Existing Firelite FCPS-24FS8(NAC3) Existing Existing Existing Firelite FCPS-24FS8(NAC4) Existing Existing Existing See Main System Record of Completion for additional Information,certifications,and approvals. j1FPA 72 ®2016 National Fire Protection Association.This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution.No other reproduction or transmission in any form permitted without written permission of NFPA.For inquiries or to report unauthorized Nr use,contact licensing©nfpa.org.