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Correspondence t-PSzo23 - c oc '/ SYSTEM RECORD OF COMPLETION Form Completion Date:09118/2023 Supplemental Pages Attached:1 1. PROPERTY INFORMATION Name of property: Tigard Senior Housing --- Address: 8803 SW Omara St Tigard OR 97223 Description of property: Apartment Building Name of property representative: Northwest Housing Alternatives Address: 2316 SE Willard St,Milwaukie,OR 97222 Phone: 503-654-1007 Fax: N/A E-mail: N/A 2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION Installation contractor: Kopper Works Flectric Address: 3772 Portland Rd NE Suite Salem,OR 97301 Phone: (503)486-7171 Fax: N/A E-mail, lakerman.kopperworkselectriccom • Service organization:GB MANCHESTER INC Address: 6000 NE 88TH ST,SUITE B105,VANCOUVER WA 98665 Phone: 360-816-0484 Fax: 360-816-0482 E-mail: nathan.b@gbmanchester.com Testing organization: GB MANCHESTER INC Address: 6000 NE 88TH ST,SUITE B105,VANCOUVER WA 98665 Phone: 360-616-0484 Fax: 360-816-0482 E-mail: nathan.b(c.gbmanchester.com Effective date for test and inspection contract: Existing Monitoring organization: GB MANCHESTER INC(DEALER FOR CSM-ESTACADA) Address: 6000 NE 88TH ST,SUITE B105,VANCOUVER WA 98665 Phone: 360-816-0484 Fax: 360-816-0482 E-mail: nathan.b[4gbmanchester.com Account number: 13-01-4664/13-03-4664 Phone line 1: N/A Phone line 2: N/A Means of transmission: 918 3 3 One-Way Private Radio Alarm System Entity to which alarms are retransmitted: BOEC Phone: 503-760-6911 3. DOCUMENTATION On-site location of the required record documents and site-specific software: DOC BOX 4. DESCRIPTION OF SYSTEM OR SERVICE This is a: m New system ❑ Modification to existing system Permit number: FPS2023-00011 NFPA 72 edition: 2016 4.1 Control Unit Manufacturer: Edwards Model number: iO1000RD 4.2 Software and Firmware Firmware revision number: 04.41.00 4.3 Alarm Verification m This system does not incorporate alarm verification. Number of devices subject to alarm verification: N/A Alarm verification set for N/A seconds N FPA 72(p.1 of 3) A. ©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 Irl' or distribution.No other reproduction or transmission in any form permitted without written permission of NFPA.For inquiries or to report unauthorized NFPit use,contact lIcensing@nfpa.org. SYSTEM RECORD OF COMPLETION (continued) 5. SYSTEM POWER -_ 5.1 Control Unit 5.1.1 Primary Power Input voltage of control panel: 120V Control panel amps: 1.0 Overcurrent protection: Type: BREAKER Amps: 20 Branch circuit disconnecting means location: CC1 - Number: 14 5.1.2 Secondary Power Type of secondary power:BATTERY.12V-18AH Location,if remote from the plant: N/A Calculated capacity of secondary power to drive the system: In standby mode(hours): 24 In alarm mode(minutes): 5 5.2 Control Unit O This system does not have power extender panels ❑Power extender panels are listed on supplementary sheet A 6. CIRCUITS AND PATHWAYS Dual Media Separate Survivability Pathway Type Pathway Pathway Class Level Signaling Line N/A 1 B 0 Device Power N/A N/A N/A N/A Initiating Device N/A N/A N/A N/A Notification Appliance N/A 12+4 spare B 0 Other(specify): N/A N/A N/A 0 7. REMOTE ANNUNCIATORS Type Location LDC DISPLAY/CONTROL Lobby 100 N/A N/A 8. INITIATING DEVICES Addressable or Alarm or Sensing Type Quantity Conventional Supervisory Technology Manual Pull Stations 2 ADDRESSABLE ALARM N/A Smoke Detectors 34 ADDRESSABLE ALARM PHOTOELECTRIC Duct Smoke Detectors N/A N/A N/A N/A Heat Detectors 2 ADDRESSABLE ALARM 135 DEG/FIXED Gas Detectors N/A N/A N/A N/A Waterfiow Switches 2 ADDRESSABLE ALARM N/A Tamper Switches 6 ADDRESSABLE SUPV. N/A NFPA 72(p.2 of 3) ®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 IicensingQnfpa.org. SYSTEM RECORD OF COMPLETION (continued) 9. NOTIFICATION APPLIANCES CCA PORTABLES ONLY - Type Quantity Description Audible 116 Low Frequency Horn - Visible 32 STROBE Combination Audible and Visible 32 HORN-STROBE 10. SYSTEM CONTROL FUNCTIONS Type Quantity Hold-Open Door Releasing Devices 1 HVAC Shutdown 2 Fire/Smoke Dampers 3 Door Unlocking N/A Elevator Recall 1 Elevator Shunt Trip 1 N/A N/A N/A N/A 11. INTERCONNECTED SYSTEMS j 0 This system does not have interconnected systems. 0 Interconnected systems are listed on supplementary sheet . 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: ROB NIXON Printed name: ROB NIXON Date: 09/18/2023 Organization:GB MANCHESTER INC Title: TECHNICIAN Phone: 360-624-8445 12.2 System Operational Test This system as specified herein has tested according to all NFPA standards cited herein. Signed: ROB NIXON Printed name: ROB NIXON Date: 09/18/2023 Organization:GB MANCHESTER INC Title: TECHNICIAN Phone: 360-624-8445 12.3 Acceptance Test Date and time of acceptance test: 09/18/2023 Installing contractor representative: ROB NIXON,GB MANCHESTER INC ' Testing contractor representative: ROB NIXON,GB MANCHESTER INC Property representative: AHJ representative: NFPA 72(p.3 of 3) N Qt ©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 use,contact licensing@nfpa.org. NOTIFICATION APPLIANCE POWER PANEL SUPPLEMENTARY RECORD OF COMPLETION Form Completion Date: 09/18/2023 Number of Supplemental Pages Attached: 1 1. PROPERTY INFORMATION Name of property: Tigard Senior Housing Address: 8803 SW Omara St Tigard OR 97223 2. NOTIFICATION APPLIANCE POWER EXTENDER PANELS Make and Model Location Area Served Power Source FACP Electric Room 103 Level B1 CC1#14 EST BPS6A(NAC1) Electric Room 103 Level 1 CC1#18 EST BPS6A(NAC2) Electric Room 103 Level 2 CC1#20 EST BPS6A(NAC3) Electric Room 370 Levels 38.4 P2#12 See Main System Record of Completion for additional information,certifications,and approvals. NFPA 72 t ®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.