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Report (643) fis 741 )'SYaTEM RECORD OF COMPLETION t 4 This form is to be completed by the sy=stem installation contractor at the time ofsystem acceptance and approve l. It shall be permitted to nrodift this fot m 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: /'L 7 - '' Supplemental Pages Attached: 1. PROPERTY INFORMATION - s-s Name of property: �i "�'� ` r-- 7- or/ !• �o �J - • Description of property: Name of property representative: Address: Phone: Fax: E-mail: 2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION Installation contractor. Address: � t 6 : Phone: „9,4=4,2_,2x.4112 v Fax: E-mail: Service organization: Address: Phone: Fax: Testing organization: Address: Phone: Fax: E-mail: 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 t and sire-specific software: of the required reearsi documents Ott-sitz location 9 4. DESCRIPTION OF SYSTEM OR SERVICE fps a� l�— d�aa I This is a: ❑New system ,Modification to existing system Permit number: NFPA 72 edition: 4.1 Control Unit �Q �^) / C�1 Model number: Manufacturer. J 4.2 Software and Firmware Firmware revision number. This system does not incorporate alarm verification. 4.3 Alarm Verification seconds Number of devices subject to alarm verification: Alarm verification set for Copyd9ht 2012 NatUenat Fire Protection Association.This form may ea copied tar 1mJ'ivdual use enter teenier resale_It may not be copied let Commercial 3215 m tfislributior•. SYSTEM RECORD OF COMPLETION(continued) 40. 6. SYSTEM POWER 5.1 Control Unit 5.1.1 Primers'Power input voltage of control panel: ! 2 0 VA C. Control panel amps: , Overcurrent protection: Type: $2 Amps: 7.0 Z5Branch circuit disconnecting means location: d r4 / Number. V2-- 5.1.2 .12 Secondary Power �- Type of secondary power: -31k l ► ,5 -2 LI- H Location,if remote from the plant: Calculated capacity of secondary_power to drive the system: In standby mode(hours): +4� 4/ In alarm mode(minutes): 5.2 Control Unit ❑ This system does not have power extender panels ❑ Power extender panels are listed on supplementary sheet A 6. CIRCUITS AND PATHWAYS Pathway Type j Dual Media Pathway Separate Pathway Class Survivability Level I I Signaling Line Device Power I I Initiating Device ! 4 { Notification Appliance f Other(specify): 7. REMOTE ANNUNCIATORS Type I Location tit//ott., 8. INITIATING DEVICES Addressable or Type Quantity Conventional Alarm or Supervisory Sensing Technology Manual Pull Stations } Smoke Detectors 1 Duct Smoke Detectors I I Heat Detectors An1111111111111111111111111111111 Gas Detectors I I Waterilow Switches I I Tamper Switches 1 I I Copytcht©2O12 National Ara prctecreon Assedaticn.This icon may be copied for individual use other than for resale.It may not be copied:Of commercial sale Cr distribuliion. II i 4. N SYSTEM RECORD OF COMPLETION(continued) 9. NOTIFICATION APPLIANCES Type I Quantity I Description Audible 1 2 , 3 Visible I I tAfi-.e' !06-4- Combination Audible and Visible ( / 1 Wh. .€4( _ -- 'i0. SYSTEM CONTROL FUNCTIONS Type y� Quantity Hold-Open Door Releasing Devices l HVAC Shutdown Fire/Smoke Damper f Door Unlocking / k Elevator Recall / 1 Elevator Shunt Trip I 'ii, INTERCONNECTED SYSTEMS 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 ed herein as installed according to all NFPA standards cited herein.� � � Signed: rPrinted name: v r'1 4e4 Lie Date: / — 2 7 — / 2 Organization: r, I p. 1 o N tT s� Title: N S I H'//e - Phone: 3 t CY_ D.y 12.2 System Operational Test This systema . Med li re' h ed according to all NFPA standards cited herein. % fS ��11 `l /- Z7- / 7 Signed: Printed name: Date Organize on: ?p r N r, J.✓r V(10..__Title: '�ilJ S'-/7,4 / I Lyrt„, Phone: c 3-?J'fo- Tt)-L1\ 12.3 Acceptance Test Date and time of acceptance test Installing contractor representative: Testing contractor representative: Property representative: AH3 representative: Copyricht 02012 National Fire P-otee.ien Assc aticri_This ram may be=pied tat individual su-s cin than Wraasale.It may=be copied for c.:nrnerdat sate or eisiribuiien.