Permit "4'.R I BUILDING PERMIT
CT PE RMIT #: BUP2005 -00637
'._�I�' , DEVELOPMENT E r o
SERVICES DATE ISSUED: 12/27/2005 13125 SW Hall
PARCEL: 2S113AD -01700
SITE ADDRESS: 16920 SW 72ND AVE ZONING: C -G
SUBDIVISION: ROSEWOOD ACRE TRACTS LOT: 030 JURISDICTION: TIG
Project Description: TI
REISSUE: FLOOR AREAS EXTERIOR WALL CONSTRUCTION
CLASS OF WORK: ALT FIRST: sf N: S: E: W:
TYPE OF USE: COM SECOND: sf PROJECT OPENINGS?
TYPE OF CONST: : sf N: S: E: W:
OCCUPANCY GRP: TOTAL AREA: 0 sf ROOF CONST: FIRE RET?
OCCUPANCY LOAD: BASEMENT: sf AREA SEP. RATED:
STOR: HT: ft GARAGE: sf OCCU SEP. RATED:
BSMT ?: MEZZ ?: REQD SETBACKS REQUIRED
FLOOR LOAD: psf LEFT: ft RGHT: ft FIR SPKL: SMOK DET:
DWELLING UNITS: FRNT: ft REAR: ft FIR ALRM : HNDICP ACC:
BEDRMS: BATHS: IMP SURFACE: PRO CORR: PARKING:
VALUE: $ 260,000.00
Owner: Contractor:
BRIDGEPORT LAND LLC SD DEACON ENTERPRI INC (77875)
3939 NW ST HELENS RD PO BOX 25392
PORTLAND, OR 97210 PORTLAND, OR 97298 -0392
Phone: 503 - 224 -2676 Contact #: PRI 503 - 297 -8791
FAX 503 - 297 -8997
FEES Reg #: LIC 77875
Description Date Amount REQUIRED ITEMS AND REPORTS
[FLS] FLS Pln Rv 12/12/200E $422.52
[BUPPLN] Addl Pln Rv 12/27/200E $50.70
[BUPPLN] Pln Rv 12/12/200E $686.60
[FLS] Addl FLS PlnRv 12/27/200E $31.20
(additional fees not listed here)
Total $2,416.06
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 than 180 days. ATTENTION: Oregon law
requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set /orth . OAR
952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of these rules or direct • , es ions to a NC by
calling 503 -246 699 or 1- 800 -332— ' 4.
Issued By. -/_, . � _ ter A , _ _
, . ,_ Permittee Signature:, ; ,1 ,J, � dj,
/ / - j
Call 503 - 639 -4175 by 7:00 a.m. for an inspection that business day.
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.
i m Perm • Ap J' I Ko IC l h�sl�cl i X,: "' *
/ l `My� ' k
City of Tigard �O Received / � /9 permit No.: ���
{� � Deceive. �/ t�V 32
13125 SW Hall Blvd., Tigard, OR 97223 J 0� Plan Review
Phone: 503.639.4171 Fax: 503.598.1960 0:2,0 „5;L.,.71¢?:� i'i '' Date/By. Other Permit:
Inspection Line: 503.639.4175 '0 -- OG GI \\-1 c\� _ _ __ Date Ready/By: ten ® See Attached Checklist for
Internet: www.ci.tigard.or.us GO \\& Notified/Method: • Supplemental Information
TYPE OF WORK REQUIRED DATA: 1- AND 2- FAMILY DWELLING
❑ New construction ❑ Demolition Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
Addition /alteration/replacement []"Other: T ir o4 �... equipment, materials, labor, overhead, and the profit for the
CATEGORY OF CONSTRUCTION work indicated on this application.
•
❑ I- and 2 -family dwelling Commercial /industrial Valuation: $
Lb
El Accessory building El Multi-family Number of bedrooms:
❑ Master builder ❑ Other: Number of bathrooms:
. JOB SITE INFORMATION AND LOCATION Total number of floors:
Job site address: 14, 9.10 t 5 ( ,,), '7'2_ ^�`- A , New dwelling area: square feet
City /State /ZIP: ; u to ,k , OCtg,.c., , 97 a_a. Y Garage /carport area: square feet
Suite/bldg. /apt. no.: Project name: OS (..3 S. Covered porch area: square feet
Cross street /directions to job site: t r) .t i t lsk.Cr pro k R :. , `` Deck area: square feet
F r,,,...- r o e > T ° c + e -k. T 1' \ e.-G\ Other structure area: square feet
Lo -O's s A , Tt r,. C.1 *, 12 tsl t oeo', ,d't-1 C A Li” REQUIRED DATA: COMMERCIAL -USE CHECKLIST
Subdivision: RnSF eock Acs-e____. Ti ..--k4 Lot no.: 030 Permit fees* are based on the value of the work performed.
Indicate the value (rounded to the nearest dollar) of all
Tax map /parcel no.: 1S' 1: A 0 -01700
equipment, materials, labor, overhead, and the profit for the
DESCRIPTION OF WORK ' ' p . work indicated on this application.
L r1n 1; �; r U
e- i r.A 'tcJ ;`i •.L . Gv�uk i.r {;�'I
tuir.,� Valuation: S '��d / Q
[_ � a • , d - - f y r 1 P c .� Existing building area: 1g � �j square feet
�t F• New building area: ^ � it r c-a square feet
. ❑ PROPERTY OWN ER - , TENANT d . Number of stories: f/ 3 ?
Name: \ ) S � ) Type of construction: - F t „ A i p ,, pco d (.„ , k
Address: ¢4 So l t:1,--K 7N-=‘ fir k �,7 Occupancy groups:
City /State /ZIP: <: (bl—V�vn'�v / u 43'Z n Existing: B.2.„, Phone: 414c) ' 38 44 l Z Fax: (CA41 5 4 - 2. 40 New: M
❑ APPLICANT CONTACT PERSON NOTICE
Business name: ())9n+`c -Lhr, ���,5 - '$ % All contractors and subcontractors are required to be
licensed with the Oregon Construction Contractors Board
Contact name: '
�O'r W `J
� -, e- I , under ORS 701 and may be required to be licensed in the
Address: (-57 �Q SW 1.3„xn..C.t Gf4 �{ U e..4` i "- jurisdiction in which work is being performed. If the
City /State /ZIP: Poc I G-r`r� C7 (� 9-7-1.. e(a 4-/.2.-2.4 applicant is exempt from licensing, the following reasons
apply:
Phone: ( cin)2i 7 - 87q ( Fax: :(Sp') ZQi Siq?
E -mail: N iC,,,h \• ,', L Lkt:.t®' • (-0 s'-'.... ,
CONTRACTOR .
Business name: C et ' �V
L
`� BUILDING PERMIT FEES*
Address: Cr j :t_C / P.r� e+E c 4O -l'.. t .ii c c.,.. �"
Please refer to fee schedule.
City /State /ZIP: P 1 j, O &� s C (72 ? •2.E 4 Fees due upon application 1
F� �p
Amount received
Phone: (�? Zq 7 0 ax:( ) - C � 9
CCB lic.: " %
' /7.,. Date received:
Authorized signature: This permit application expires if a permit is not obtained
/ within 180 days after it has been accepted as complete.
Print name: ` N. `..� N \ Date: ` �•J t �r ci S * Fee methodology set by Tri- County Building Industry
11 t Service Board.
1:\ Building \Permits\BUP- TI- PermitApp.doc 12/03 440- 4613T(I l /02/COM/WEB)
Building Division
4 """' "'"0 ' ;' Plan Submittal Requirement Matrix
I � :. Commercial & Multi- Family - New, Additions or Alterations
ity of Tigard
Type of Submittal # of Plans
(Includes new, additions and alterations.) Required at
Sub II ittal
Demolition Permit 2
(site plan required showing location and square
footage of all buildings to be demolished)
Site ork 2
(must i lude location of all accessible p. ing)
Plumbing (si . utilities) 2
Building 1*
Fire Pro ction System 3 **
Mechanical 2
Plumbing (building fixtures) 2
Electrical 2
Plan review is dependent upon submittal of a completed application and plans.
After plan review approval, the Plans Examiner will contact the applicant to request
additional sets of plans for distribution purposes (for contractor, City of Tigard,
Washington County, and Tualatin Valley Fire & Rescue)
* For over -the- counter commercial tenant improvements, submit 2 sets of plans.
** "New" fire protection systems require that plans bear the original seal of an
Oregon licensed fire suppression engineer, or NICET level "3" technicians.
i:\ Building \Permits\BUP- T1- PermitApp.doc 12/03 440-4613T(11/02/COM/WEB)
C ITY OF TI CERTIFICATE OF OCCUPANCY
w I � '. DEVELOPMENT SERVICES PERMIT #: BUP2005 - 00637
III 13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 DATE ISSUED: 12/27/2005
PARCEL: 2S 113AD - 01700
ZONING: C -
JURISDICTION: TIG
SITE ADDRESS: 16920 SW 72ND AVE
SUBDIVISION: ROSEWOOD ACRE TRACTS
BLOCK: LOT: 030
CLASS OF WORK: ALT
TYPE OF USE: COM
TYPE OF CONSTR: 5N
OCCUPANCY GRP: M
OCCUPANCY LOAD: 553
TENANT NAME: DSW SHOES
REMARKS: TI
Owner:
BRIDGEPORT LAND LLC
3939 NW ST HELENS RD
PORTLAND, OR 97210
Phone: 503 - 224 -2676
Contractor: 503 - 297 -8791
SD DEACON ENTERPRI INC (77875)
PO BOX 25392
PORTLAND, OR 97298 -0392
Phone: 503- 297 -8791
503 -297 -8997
Reg #: LIC 77875
This Certificate issued 3/30/2006 grants occupancy of the above referenced building or
portion thereof and confirms tha e building has been inspected for compliance with
the to e of Oregon Spe ialty odes for the group, ' ccup : ncy, and use under which the
refere Led perm' wa JJ is. -
4110111AL laftd" ,v o
BUI • . TOR BUILDIN
POST IN CONSPICUOUS PLACE
CI 1 ! IGARD
BUILDING DIVISION PERMIT #:e144 V - ®O(,37
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED:
Phone: (503) 639 -4171 a.
Inspection Requests (24 Hrs.): (503) 639 -4175
INSPECTION WORKSHEET FOR DATE: TIME: (m at) ,4A& PAGE:
SITE ADDRESS: I (09)- � � , / CLASS OF WORK:
SUBDIVISION: LOT #: TYPE OF USE:
PROJECT NAME:
DESCRIPTION: •
OWNER: PHONE 00 7 — 13i
CONTRACTOR: O".. , (� PHONE
V
Inspection Request Scheduled For: Date: 3 - 3-0 --op Pour Time:
Code # Inspection Description Confirm # Contact # Message
Corrections /Comments /Instructions:
MOM
PASS n PARTIAL APPROVAL ❑ CANCEL n NO ACCESS
n FAIL I I CALL FOR INSPECTION ❑ ADDITIONAL EES ASSESSED
Inspector: •` Date: ' , � __ Phone #: (503) 718-
CI - - OF TIGARD 6"--W
BUILDING DIVISION PERMIT #:a O63 Od 6 3 7
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED:
Phone: (503) 639 -4171 ��, �
Inspection Requests (24 Hrs.): (503) 639 -4175 a , 1, . �__L,
INSPECTION WORKSHEET FOR DATE: TIME: PAGE:
SITE ADDRESS: J b 9,_ U 7 a , 4//ct i CLASS OF WORK:
SUBDIVISION: ` LOT #: TYPE OF USE:
PROJECT NAME:
DESCRIPTION:
OWNER: PHONE #:
CONTRACTOR: PHONE #:
Inspection Request Scheduled For: Date: 3 - Z g 0 ( Pour Time:
Code # Inspection Description Confirm # Contact # Message
2 / .L2) 709 -131 4
Corrections /Comments /Instructions: G(A.,erG\Azii,c
f, 1 / , •
,,
J fJ ',/-
n PA ❑ PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
FAIL n CALL FOR INSPECTION El ADDITIONAL F •S ASSESSED
Inspector:
A � � =1 -
i Dater ' • Phone #: (503) 718-
a ,\ TIGARD
■ IGARD
BUILDING DIVISION PERMIT #: IIa.II�:A{.3flt: >- t3,iis;i7
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 12,27/2005
Phone: (503) 639 -4171 I
Inspection Requests (24 Hrs.): (503) 639 -4175 P �I1i
INSPECTION WORKSHEET FOR DATE: 7122/2016 TIME: 7.02 PAGE: 62
SITE ADDRESS: 16920 SW 72ND AVE CLASS OF WORK:
SUBDIVISION: RQSj_-WO j ACRE TRACTS LOT #: 030 TYPE OF USE:
PROJECT NAME: ryS SNOES
DESCRIPTION: ❑
OWNER: BRIDGEPORT l.ANC) LLC, PHONE #: b0 3- 21,„2`;/8
CONTRACTOR: St) DEACON EN rE:RPRI INC (7; 876) PHONE #: 603,_ 4297, 1 79 i
Inspection Request Scheduled For: Date: 2122/2006 Pour Time:
Code # Inspection Description Confirm # Contact # Message
737 Sti.,l:r , flded ceiling 027293 -02 5()3- 7091314 i
Corrections /Comments /Instructions:
— (U 5Ttct c L CO( �
Q, do
C .
W t. 4 ' ''' li....... ,..
1 PASS PARTIAL APPROVAL n CANCEL ❑ NO ACCESS
FAIL n CALL FOR INSPECTION n ADDITIONAL F ES ASSESSED
Inspector: � fl‘ 2.' v 6 Phone #: (503) 718 - 77,2__
CI .. ` =f TIGARD
BUILDING DIVISION PERMIT #: tl � }�S:;c it °z.t' � R
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 12/270006
Phone: (503) 639 -4171 ! tea A
, � �1(1
Inspection Requests (24 Hrs.): (503) 639 -4175
INSPECTION WORKSHEET FOR DATE: 3J9f200t; TIME: 7:041AM PAGE: Q
•
SITE ADDRESS: 10:320 SW 72ND AVE CLASS OF WORK:
SUBDIVISION: ROSEWOOD ACRE 'IRAGFS LOT #: OM TYPE OF USE
PROJECT NAME: DS W SHOES
DESCRIPTION: 11
OWNER: BRIDGEPORT LAND LLC, PHONE #: &D3 22420/(;
CONTRACTOR: S() DEACON EWTERPRI iNf: (7Th/) PHONE #: 503-297..ta9 I
Inspection Request Scheduled For: Date: 2 /912006 Pour Time:
Code # Inspection Description Confirm # Contact # Message
2B/ . t)u; encde d ceiling 0265f:6- 01 1,- ;03- 779.1314 N
Corrections /Comments /Instructions:
rTh ._
. .
•
•
',.--.-/ .( A f , ,
i _...... Ai '\ i
, , wow , ira .„,„---
•
1 I PASS , PARTIAL APPROVAL ❑ CANCEL ❑ NO ACCESS
n FAIL 1 1 CALL FOR INSPECTION ❑ ADDITIONAL r EES ASSESSED
( . ,_ A _,., .._,
'J
Inspector: Date: C� , � 1 a Phone #: (503) 718 - 17
.CI Y DF TIGARD
BUILDING DIVISION PERMIT #: ; 0+ .0f3(;'S7
13125 SW Hall Blvd., Tigard, OR 97223 DATE ISSUED: 12j270006
Phone: (503) 639 -4171
Inspection Requests (24 Hrs.): (503) 639 -4175
INSPECTION WORKSHEET FOR DATE: 1/30/2006 TIME: 1:01AM PAGE: 4
SITE ADDRESS: 16920 SW 72ND AVE CLASS OF WORK:
SUBDIVISION: CZ()3EVV)Of) ACRE TRACTS LOT #: 030 TYPE OF USE:
PROJECT NAME: DSW SHOES
DESCRIPTION: °(I
OWNER: BRIDGEPORT LAND LLC, PHONE #: 50:;.-;12,3 -2. ;/5
CONTRACTOR: SD DEACON EN rERPRI INC (771376) PHONE #: 503 - ?97.0791
Inspection Request Scheduled For: Date: 1/3W2006 Pour Time:
Code # Inspection Description Confirm # Contact # Message
275 Framing 02596 :3M1 503- 709-1314 N
Corrections /Comments/ Instructions:
•
k k
U
AvP SS P ARTIAL APPROVAL NO ACCESS C ANCEL
n n ❑
❑ FAIL n CALL FOR INSPECTION n ADDITIONAL FE S ASSESSED
Inspector: ',•
S
Date: ( Q 9 #: 503 718 - 41 z 3
p ( )
f
---• 6 () P 7c-uS c:,(. 3
F UNDAMENTALS OF FIRE ALARM SYSTEMS 72 -31
FIRE ALARM SYSTEM
RECORD OF COMPLETION .
Name of prote w Sr\0 •
Address: i WA b 4 l/) 12-Nr, Tf&
Representative of protected property (name /phone):
Authority having jurisdiction:
Address/telephone number:
Organization name/phone Representative name/phone
Installer N CSt\l_ iZ T IC J 5D3 —(pLS -�'" "
Supplier
Service organization
Location of record (as- built) drawings: w MA' Y'r1n (sJ .L.
Location of operation and maintenance manuals: I�Jt��} F 1/`1't..---
Location of test reports: KAIIN ALArvin PAN fJL'
k A contract for test and inspection in accordance with NFPA standard(s)
Contract No(s): Effective date: Expiration date:
System Software
(a) Operating system (executive) software revision level(s):
(b) Site - specific software revision date:
(c) Revision completed by:
(name) (firm)
1.Type(s) of System or Service
NFPA 72, Chapter 6 — Local
If alarm is transmitted to location(s) off premises, list where received:
NFPA 72, Chapter 8 — Remote Station ,
Telephone numbers of the organization receiving alarm: ,
Alarm:
Supervisory:
Trouble:
If alarms are retransmitted to public fire service communications centers or others, indicate location and telephone
numbers of the organization receiving alarm:
Indicate how alarm is retransmitted:
NFPA 72, Chapter 8 — Proprietary
Telephone numbers of the organization receiving alarm:
Alarm:
Supervisory:
Trouble:
If alarms are retransmitted to public fire service communications centers or others, indicate location and telephone
numbers of the organization receiving alarm:
/Indicate how alarm is retransmitted:
V NFPA 72, Chapter 8 — Centrpl Station
Prime contractor: C�`cft ( ' " / - 9G O rd is b `-/ 4 4.3
Central station location:
(NFPA 72, 1 of 4)
FIGURE 4.5.2.1 Record of Completion.
2002 Edition
72-32 NATIONAL FIRE ALARM CODE
Means of transmission of signals from the protect d premises to the central station:
McCulloh Multiplex One -way radio
Digital alarm communicator Two -way radio, Others
Means of transmission of alarms to the public fire service. communications.center, ' •
(a) PDT
(b) GF LU-RaN "
System location: ELF 1T fltc, rrn.
NFPA 72, Chapter 9.— Auxiliary . -
Indicate type of connection: Local energy 'Shunt Parallel telephone
Location of telephone number for receipt of signals:
2. Record of System Installation .
(Fill out after installation is complete and wiring is checked for opehs, shorts; ground•faults improper branching,
but prior to conducting operational acceptance tests.)
This system has been installed in accordance with the NFPA standards as shown below, was inspected by
on , includes the devices shown
in 5 and 6, and has been in service since
NFPA 72, Chapters cr 2 3 4 5 6 7 8 9 10 11 (circle all that apply)
NFPA 70, National Electrical Code, Article 760
Manufacturer's instructions
Other (specify):
Signed: Date:
Organization:
3. Record of System Operation
Documentation in accordance with Inspection Testing Form, Figure 10.6.2.3, is attached
All operational features and functions of this system were tested by date
and found to be operating properly in accordance with the requirements of:
NFPA 72, Chapters 1 2 3 4 5 6 7 8 9 10 11 (circle all that apply)
NFPA 70, National Electrical Code, Article 760
Manufacturer's instructions
Other (specify):
Signed: Date:
Organization:
4. Signaling Line Circuits
Quantity and class of signaling line circuits connected to system (see NFPA 72, Table 6.6.1):
Quantity: Style: Class:
(NFPA 72, 2 of 4)
FIGURE 4.5.2.1 Continued
2002 Edition
4 FUNDAMENTALS OF FIRE ALARM SYSTEMS 72 -33
5. Alarm- Initiating Devices and Circuits
Quantity and class of initiating device circuits (see NFPA 72, Table 6.5):
Quantity: Style: Class:
MANUAL
(a) Manual stations Noncoded I Transmitters Coded Addressable
(b) Combination manual fire alarm and guard's tour coded stations
AUTOMATIC
Coverage: Complete Partial
Selective Nonrequired
(a) Smoke detectors Ion Photo t Addressable
(b) Duct detectors Ion Photo Addressable
(c) Heat detectors FT RR FT/RR RC Addressable
(d) Sprinkler waterflow indicators: Transmitters Noncoded Coded Addressable
(e) The alarm verification feature is disabled or enabled , changed from seconds to seconds.
(f) Other (list):
6. Supervisory Signal Initiating Devices and Circuits (use blanks to indicate quantity of devices)
GUARD'S TOUR
(a) Coded stations
(b)A_Noncoded stations
(c) Compulsory guard's tour system comprised of transmitter stations and intermediate stations
Note: Combination devices are recorded under5(b), Manual, and 6(a), Guard's Tour.
SPRINKLER SYSTEM
Check if ovided
(a) Valve supervisory switches
(b) Building temperature points
(c) Site water temperature points
(d) Site water supply level points
Electric fire pump:
(e) Fire pump power
(f) Fire pump running
(g) Phase reversal
Engine -driven fire pump:
(h) Selector in auto position
(i) Engine or control panel trouble
(j) Fire pump running
ENGINE - DRIVEN GENERATOR:
(a) Selector in auto position
(b) Control panel trouble
(c) Transfer switches
(d) Engine running
Other supervisory function(s) (specify):
(NFPA72,
FIGURE 4.5.2.1 Continued
2002 Edition
,
72 -34 NATIONAL FIRE ALARM CODE
7. Annunciator(s)
Number: Type: Location:
8. Alarm Notification Appliances and Circuits
NFPA 72, Chapter 6 — Emergency Voice /Alarm Service
Quantity of voice/alarm channels: Single: Multiple:
Quantity of speakers installed: Quantity of speaker zones:
Quantity of telephones or telephone jacks included in system:
Quantity and the class of notification appliance circuits connected to system (see NFPA 72, Table 6.7):
Quantity: Style: Class:
Types and quantities of notification appliances installed:
(a) Bells 2 With Visible 4
(b) Speakers With Visible
(c) Horns With Visible
(d) Chimes With Visible
(e) Other: With Visible
(f) Visible appliances without audible:
9. System Power Supplies �7 ��
(a) Fire Alarm Control Panel: Nominal voltage: 121:7 Gl/U Current rating: I (yo Pt
Overcurrent protection: Type: C )rc,G r Yea 1N� °Lor Current rating: 24) A
Location: PANEL IG LIF-T S
(b) Secondary (standby):
Storage battery: Amp -hour rating:
Calculated capacity to drive system, in hours:
Engine -driven generator dedicated to fire alarm system:
Location of fuel storage:
(c) Emergency system used as backup to primary power supply:
Emergency system described in NFPA 70, Article 700:
10. Comments
Frequency of routine tests and inspections, if other than in accordance with the referenced NFPA standard(s):
System deviations from the referenced NFPA standard(s) are:
(signed) for installation contractor /supplier (title) (date)
(signed) for alarm service company (title) (date)
(signed) for central station (title) (date)
Upon completion of the system(s) satisfactory test(s) witnessed (if required by the authority having jurisdiction):
(signed) representative of the authority having jurisdiction (title) (date)
(NFPA72,
FIGURE 4.5.2.1 Continued
2002 Edition
J 6o9 'l,,c0 / c)t7G-'7 \
FUNDAMENTALS OF FIRE ALARM SYSTEMS 72 -31
FIRE ALARM SYSTEM
-_
RECORD OF COMPLETION
Name of protec ed opert . w ll S P 1 o , . •
Address: 1 11 w )2r-Jr) - r t r D
Representative of protected property (name /phone):
Authority having jurisdiction: • • . •
Address/telephone number: •
Organization name /phone Representative name Iphone
• N , _ / s -- i�
Installer 11 ' 1 _ I VA
Supplier
Service organization
Location of record (as- built) drawings: w % rk-lr FN'EL
Location of operation and maintenance manuals: Wt •L..—
Location of test reports: vorm At.Arrvl f tV s--
A contract for test and inspection in accordance with NFPA standard(s)
Contract No(s): Effective date: Expiration date:
System Software
(a) Operating system (executive) software revision level(s):
(b) Site - specific software revision date:
(c) Revision completed by:
(name) (firm)
1.Type(s) of System or Service
NFPA 72, Chapter 6 — Local
If alarm is transmitted to location(s) off premises, list where received:
NFPA 72, Chapter 8 — Remote Station
Telephone numbers of the organization receiving alarm:
Alarm:
Supervisory:
Trouble:
If alarms are retransmitted to public fire service communications centers or others, indicate location and telephone
numbers of the organization receiving alarm:
Indicate how alarm is retransmitted:
NFPA 72, Chapter 8 — Proprietary
Telephone numbers of the organization receiving alarm:
Alarm:
Supervisory:
Trouble:
If alarms are retransmitted to public fire service communications centers or others, indicate location and telephone
numbers of the organization receiving alarm:
Indicate how alarm is retransmitted:
NFPA 72, Chapter 8 — Central Station
Prime contractor: Cyi•3c' it f 7 C -t -•t 7L /- 6G o - `d i' - `-/ 4 4-3
Central station location:
(NFPA 72, 1 of 4)
FIGURE 4.5.2.1 Record of Completion.
2002 Edition
72 - NATIONAL FIRE ALARM CODE
Means of transmission of signals from the protec premises to the central station:
McCulloh Multiplex One -way radio
Digital alarm communicator Two -way radio • Others
Means of transmission of alarms to the public fire service commuhicationacenter: •
(a) P
(b)CF? ��
System location: ETrtG rm. •
NFPA 72, Chapter 9.— Auxillary .
•
Indicate type of connection: Local energy Shunt • Parallel telephone '
Location of telephone number for receipt of signals:
2. Record of System Installation .. , !
(Fill out after installation is complete and wiring is checked for opehs, shorts; ground•fault, and improper branching,
but prior to conducting operational acceptance tests.)
This system has been installed in accordance with the NFPA standards as shown below, was inspected by
on , includes the devices shown
in 5 and 6, and has been in service since
_NFPA 72, Chapters 1 2 3 4 5 6 7 8 9 10 1 (circle all that apply)
NFPA 70, National Electrical Code, Article 760
Manufacturer's instructions
Other (specify):
Signed: Date:
Organization:
3. Record of System Operation
Documentation in accordance with Inspection Testing Form, Figure 10.6.2.3, is attached
All operational features and functions of this system were tested by date
and found to be operating properly in accordance with the requirements of:
_NFPA 72, Chapters 1 2 3 4 5 6 7 8 9 10 11 (circle all that apply)
NFPA 70, National Electrical Code, Article 760
Manufacturer's instructions
Other (specify):
Signed: Date:
Organization:
4. Signaling Line Circuits
Quantity and class of signaling line circuits connected to system (see NFPA 72, Table 6.6.1):
Quantity: Style: Class:
(NFPA 72, 2 of 4)
FIGURE 4.5.2.1 Continued
2002 Edition
)p <te-sC - 6 d
FUNDAMENTALS OF FIRE ALARM SYSTEMS 72 -33
5. Alarm Initiating Devices and Circuits
Quantity and class of initiating device circuits (see NFPA 72, Table 6.5):
Quantity: Style: Class:
MANUAL
(a) Manual stations Noncoded I Transmitters Coded Addressable
(b) Combination manual fire alarm and guard's tour coded stations
AUTOMATIC
Coverage: Complete - Partial
Selective Nonrequired
(a) Smoke detectors Ion Photo t Addressable
(b) Duct detectors lon Photo Addressable
(c) Heat detectors FT RR FT/RR RC Addressable
(d) Sprinkler waterflow indicators: Transmitters Noncoded Coded Addressable
(e) The alarm verification feature is disabled or enabled , changed from seconds to seconds.
(f) Other (list):
6. Supervisory Signal Initiating Devices and Circuits (use blanks to indicate quantity of devices)
GUARD'S TOUR
(a) Coded stations
(b)_1__Noncoded stations . •
(c) Compulsory guard's tour system comprised of transmitter stations and intermediate stations
Note: Combination devices are recorded under 5(b), Manual, and 6(a), Guard's Tour.
SPRINKLER SYSTEM
Check if ovided
(a) Valve supervisory switches
(b) Building temperature points
(c) Site water temperature points
(d) Site water supply level points
Electric fire pump:
(e) Fire pump power
(f) Fire pump running
(g) Phase reversal
Engine -driven fire pump:
(h) Selector in auto position
(i) Engine or control panel trouble
(j) Fire pump running
ENGINE - DRIVEN GENERATOR:
(a) Selector in auto position
(b) Control panel trouble
(c) Transfer switches
(d) Engine running
Other supervisory function(s) (specify):
(NFPA 72, 3 of 4)
FIGURE 4.5.2.1 Continued
2002 Edition
•
72 -34 NATIONAL FIRE ALARM CODE
7. Annunciator(s)
Number: Type: Location:
8. Alarm Notification Appliances and Circuits
NFPA 72, Chapter 6 — Emergency Voice/Alarm Service
Quantity of voice/alarm channels: Single: Multiple:
Quantity of speakers installed: Quantity of speaker zones:
Quantity of telephones or telephone jacks included in system:
Quantity and the class of notification appliance circuits connected to system (see NFPA 72, Table 6.7):
Quantity: Style: Class:
Types and quantities of notification appliances installed:
(a) Bells 2 With Visible 4
(b) Speakers With Visible
(c) Horns With Visible
(d) Chimes With Visible
(e) Other: With Visible
(f) Visible appliances without audible:
9. System Power Supplies �7
(a) Fire Alarm Control Panel: Nominal voltage: 12.0 2 Current rating: bd 14
Overcurrent protection: Type: c rL6 r 1neX- Current rating: 20 A
Location: PAWL ICI C"ra S
(b) Secondary (standby):
Storage battery: Amp -hour rating:
Calculated capacity to drive system, in hours:
Engine -driven generator dedicated to fire alarm system:
Location of fuel storage:
(c) Emergency system used as backup to primary power supply:
Emergency system described in NFPA 70, Article 700:
10. Comments
Frequency of routine tests and inspections, if other than in accordance with the referenced NFPA standard(s):
System deviations from the referenced NFPA standard(s) are:
(signed) for installation contractor /supplier (title) (date)
(signed) for alarm service company (title) (date)
(signed) for central station (title) (date)
Upon completion of the system(s) satisfactory test(s) witnessed (if required by the authority having jurisdiction):
(signed) representative of the authority having jurisdiction (title) (date)
(NFPA 72, 4 of 4)
FIGURE 4.5.2.1 Continued
•
2002 Edition