HomeMy WebLinkAboutPermit { DOCUMENTATION F�2(�23—OL.p(o7 72-39
SYSTEM RECORD OF COMPLETION
This form is to be completed by the system installation contractor at the time of system acceptance and approval.
It shall be permitted to modify this form as needed to provide a more complete and/or clear record.
Insert N/A in all unused lines.
Attach additional sheets,data,or calculations as necessary to provide a complete record.
Form Completion Date: Supplemental Pages Attached:
1. PROPERTY INFORMATION
Name of property: WANG S GROCERY
Address: 11655 SW PACIFIC HWY,TIGARD,OR 97223
Description of property:
Name of property representative:
Address:
Phone: Fax: E-mail:
2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION
Installation contractor: ACTION TECHNOLOGY SYSTEMS LLC
Address: 835 SE 17TH AVENUE PORTLAND OR 97214
Phone: 503-231-1992 Fax: E-mail: SUPPORT@ACTIONTECHNOLOGY.COM
Service organization:ACTION TECHNOLOGY SYSTEMS LLC
Address: 835 SE 17TH AVENUE PORTLAND OR 97214
Phone: 503-231-1992 Fax: E-mail: SUPPORTatACTIONTECHNOLOGY.COM
Testing organization: ACTION TECHNOLOGY SYSTEMS LLC
Address: 835 SE 17TH AVENUE PORTLAND OR 97214
Phone: 503-231-1992 Fax: E-mail: SUPPORTQACTIONTECHNOLOGY.COM
Effective date for test and inspection contract:
Monitoring organization: CENTRAL STATION MONITORING
Address: 303 SW ZOBRIST,ESTACADA,OR 97023
Phone: 503-231-6625 Fax: E-mail:
Account number: 51-9923 Phone line 1: Phone line 2:
Means of transmission: DMP CELL COMMUNICATOR
Entity to which alarms are retransmitted: Phone:
3. DOCUMENTATION
On-site location of the required record documents and site-specific softwaret'DOCUMENT CAN ADJACENT FACP
4. DESCRIPTION OF SYSTEM OR SERVICE
This is a: l New system Cl Modification to existing system Permit number: FPS2023-00062
NFPA 72 edition: 2016
4.1 Control Unit
POTTER AFC50
Manufacturer: Model number:
4.2 Software and Firmware
Firmware revision number:
4.3 Alarm Verification ®This system does not incorporate alarm verification.
Number of devices subject to alarm verification: NONE Alarm verification set for seconds
0 2015 National Fire Protection Association NFPA 72(p.1 of 3)
FIGURE 7.8.2(a) System Record of Completion.(SIG-FUN)
2016 Edition 14
72-40 NATIONAL FIRE ALARM AND SIGNALING CODE
SYSTEM RECORD OF COMPLETION (continued)
5. SYSTEM POWER
5.1 Control Unit
5.1.1 Primary Power
Input voltage of control panel: 120vac Control panel amps: 5
Overcurrent protection: Type: Amps:
Branch circuit disconnecting means location: Number:
5.1.2 Secondary Power
Type of secondary power: SEALED LEAD ACID 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): 5
5.2 Control Unit
VI 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 1 B 0
Device Power
Initiating Device
Notification Appliance 3 B 0
Other(specify):
7. REMOTE ANNUNCIATORS
Type Location
LCD ENTRY LOBBY
8. INITIATING DEVICES
Addressable or Alarm or Sensing
Type Quantity Conventional Supervisory Technology
Manual Pull Stations 4 ADDRESSABLE ALARM
Smoke Detectors 1 ADDRESSABLE ALARM PHOTO
Duct Smoke Detectors
Heat Detectors
Gas Detectors
Waterflow Switches
Tamper Switches
02015 National Fire Protection Association NFPA 72(p.2 of 3)
FIGURE 7.8.2(a) Continued
.`w>! 2016 Edition
DOCUMENTATION 72-41
SYSTEM RECORD OF COMPLETION (continued)
9. NOTIFICATION APPLIANCES
Type Quantity Description
Audible
Visible 5 STROBES
Combination Audible and Visible 13 HORN/STROBES
10. SYSTEM CONTROL FUNCTIONS
Type Quantity
Hold-Open Door Releasing Devices
HVAC Shutdown
Fire/Smoke Dampers
Door Unlocking
Elevator Recall
Elevator Shunt Trip
11. INTERCONNECTED SYSTEMS
b This system does not have interconnected systems.
❑ Interconnected systems are listed on supplementary sheet
12. CERTIFICATION AND APPROVALS
12.1 System Installation Contractor
This as sped elerein has been installed according to all NFPA standards cited herein.
Signed Printed name: STEVEN A BARRY Date:(p/1 f Z s
Organization: ACTION TECHNOLOGY S EMS LLC Title: PROJECT MANAGER Phone: 503-231-1992
12.2 System Operational Test
This system as specified herein has tested according to all NFPA standards cited herein.
Signed: Printed name: Date:
Organization: ACTION TECHNOLOGY SYSTEMS LLC Title: INSTALLATION ELECTRICIAN phone: 503-231-1992
12.3 Acceptance Test
Date and time of acceptance test:
Installing contractor representative:
Testing contractor representative:
Property representative:
AHJ representative:
02015 National Fire Protection Association NFPA 72(p.3 of 3)
FIGURE 7.8.2(a) Continued
2016 Edition
l
m'l
CITY OF TIGARD FIRE PROTECTION SYSTEM PERMIT
I COMMUNITY DEVELOPMENT Permit#: FPS2023-00062
Date Issued: 5/25/2023
T t C3 A RD 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 1 S136CA11900
Jurisdiction: Tigard
Site address: 11655 SW PACIFIC HWY
Project: Wang's Market Subdivision: 2021-021 PARTITION PLAT Lot: 3
Project Description: Fire alarm system in lieu of sprinkler system.
Contractor: ACTION TECHNOLOGY SYSTEMS LLC Owner: AMAN,WALTER S CREDIT SHELTER TR ET AL
835 SE 17TH AVE %82ND BURNSIDE LLC
PORTLAND, OR 97214 BY NGUYEN, HOANG
8122 SE TIBBETS ST
PORTLAND, OR 97206
PHONE: 503-231-1992 PHONE:
FAX: 503-231-1402
FEES
Description Date Amount
Specifics: Permit Fee-COM 05/25/2023 $156.00
12%State Surcharge-Building 05/25/2023 $18.72
Type of Use: COM Plan Review-Fire Life Safety-COM 05/25/2023 $62.40
Class of Work: ALT Type of Const: VB Info Process/Archiving-Sm$0.50(up to 05/25/2023 $19.00
Occupancy Grp: M Height: 1 ft 11x17)
Stories: 1
Commercial Sprinkler System:
Sprinkler Required: Sprinkler Type:
Standpipe Required: Hazard:
Density: 0 Design Area: 0
K Factor: 0
Commercial Fire Alarm System:
Fire Alarm Required: Yes Alarm Type: Automatic
Pull Station Required: No Smoke Detectors Req: No
Battery Calcs Provided: Yes Cut Sheets Required: Yes
Total $256.12
Valuations: Required Items and Reports(Conditions)
Sprinkler Valuation: $0.00
Residential Square Footage: 0
Fire Alarm Valuation: $0.00
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other
applicable law. All work will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of
issuance, or if work is suspended for more the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon
Utility Notification Center. Those r les are set f h in OAR 952-001-0010 through OAR 952-001-0090. You may obtain a copy of the rules
Issued By: Permittee Signature: � '}(c
'ly � � f 1,
Call 503.639.4175 by 7:00 a.m.for the next available inspection date.
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
r Building Permit ApplicatCEIVED
Fire Protection System r()lz oI II( I: I sr:OvI,1
1'A 1 1 S 2023 Received �j�j
City of Tigard 15 �3 PermitNo.: t l 0a _0006D,
Date/By:
13125 SW Hall Blvd.,Tigard,OR 97 OF TIGARD Plan Review
Phone: 503.718.2439 Fax: 503.5 Date/By: v.. Other Permit:
Inspection Line: 503.639.4175 SING DIVISION Date Read/B : ^��'? Juris:
I-IG:V;t) P Y Y / SeePage2for
Internet: www.tigard-or.gov Notified Meth l y/,�j Supplemental Information
0
TYPE OF WORK REQUIRED DATA:1-AND 2-FAMILY DWELLING
4❑New construction ❑Demolition Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
I]Addition/alteration/replacement ❑Other: equipment,materials,labor,overhead,and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
0 1-and 2-family dwelling 0 Commercial/industrial Valuation: $
ElAccessory building El Multi-familyNumber of bedrooms:
ElMaster builder 0 Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address:11655 SW PACIFIC HIGHWAY New dwelling area: square feet
City/State/ZIP:TIGARD OR 97223 Garage/carport area: square feet
Suite/bldg./apt.no.: Project name:WANG MARKET Covered porch area: square feet
Cross street/directions to job site: Deck area: square feet
Other structure area: square feet
REQUIRED DATA:COMMERCIAL-USE CHECKLIST
Subdivision: Lot no.: Permit fees*are based on the value of the work performed.
Tax map/parcel no.: Indicate the value(rounded to the nearest dollar)of all
equipment,materials,labor,overhead,and the profit for the
DESCRIPTION OF WORK work indicated on this application.
FIRE ALARM SYSTEM IN LIEU OF SPRINKLR SYSTEM Valuation: $8,000.00
Existing building area: square feet
New building area: square feet
0 PROPERTY OWNER 0 TENANT Number of stories:
Name: Type of construction:
Address: Occupancy groups:
City/State/ZIP:
Existing:
Phone:( ) Fax:( ) New:
0 APPLICANT 0 CONTACT PERSON
NOTICE
Business name: All contractors and subcontractors are required to be
Contact name: licensed with the Oregon Construction Contractors Board
under ORS 701 and may be required to be licensed in the
Address: jurisdiction in which work is being performed.If the
City/State/ZIP: applicant is exempt from licensing,the following reasons
apply:
Phone:( ) Faax::( )
E-mail: 54 h,,,,vwot,4,5 l of.A. , Co`.l
, CONTRACTOR BUILDING PERMIT FEES*
Business name:ACTION TECHNOLOGY SYSTEMS LLC (Ptease refer u,fee schedule)
Permit fee:
Address:835 SE 17TH AVENUE
State surcharge(12%of permit fee):
City/State/ZIP:PORTLAND OR 97214
FLS plan review(40%of permit fee):
_ Phone:(So})231-1992 Fax:(533)231-1402 (Due upon application submittal.)
CCB lic.:157630
Total permit fees:
Authorized signature:
Amount received:
This permit application expires if a permit is not obtained
Print name: i jy 2-.1 Date: 5--t t 23 within 180 days after it has been accepted as complete.
/ V * Fee methodology set by Tri-County Building Industry
I:\Building\Permits\FPS-PermitApp_031016.doc ✓ v�y�?//-/ 440-4613T(11/02/COM/WEB Service Board.
)
•
City of Tigard: Fire Protection Permit Checklist
Page 2-Supplemental Information
Describe work to be done:
1.) Type of Work: 2.) Addition/alteration only to sprinkler heads: 3.) Addition/alteration only to alarm devices:
DNew system Number of sprinkler heads: Number of alarm devices:
❑ Addition or 0 1-10 heads: Affidavit required and ❑ 1-5 devices: Affidavit required and
Alteration (3)copies of sketch showing area (3) copies of sketch showing area
to existing of work within building structure of work within building structure
system
0 11+heads: Plan review required and 6+ devices: Plan review required and
(3)sets of plans. (3) sets of plans.
Additional description of work:
Type of System(Complete A,B,C or Das applicable):
A.) Commercial Sprinkler
Sprinkler Type ❑ Wet ❑ Dry
Additional Standpipes
Information: Sprinkler Supply Line ❑ Yes ❑ No
Hazard Group
Density
Design Area
K. Factor
Sprinkler Project Valuation: $
B.) Type I - Hood Fire Suppression System
Hood Project Valuation: $
C.) Fire Alarm
Submittal shall Battery Calculations V❑" Yes
include: Individual Component ["Yes
Cut Sheets
Fire Alarm Project Valuation: $ 000 • 00
I .) Residential Sprinkler(Stand Alone,System)
Square Footage: Permit Fee:
0 to 2,000 $198.75
2,001 to 3,600 $246.45
3,601 to 7,200 $310.05
7,201 and greater $404.39
Sprinkler Project Square Footage: sq. ft.
Fire Protection Permit Fees
Project valuation subtotal (see A,B&C above): $
Permit fee based on project valuation (see fee schedule): $
Permit fee based on square footage (see D above): $
State Surcharge (12%of permit fee): $
FLS Plan Review(40%of permit fee): $
TOTAL: $
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