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Permit CITY OF TIGARD FIRE PROTECTION SYSTEM PERMIT I l l COMMUNITY DEVELOPMENT Permit #: FPS2009 -00080 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.639.4171 Date Issued: 09/29/2009 Parcel: 2S 112AD00900 Jurisdiction: Tigard Site address: 14800 SW SEQUOIA PKWY Subdivision: Lot: 0 Project: Home Depot Project Description: Replace existing fire alarm system. • Owner: FEES THE HOME DEPOT Description Date Amount 2455 PACES FERRY RD. Permit Fee - COM 09/29/2009 $510.70 ATLANTA, GA 30339 Plan Review - Fire Life Safety - COM 08/25/2009 $204.28 PHONE: 770 - 438 -8211 12% State Surcharge - Building 09/29/2009 $61.28 Contractor: INTEGRATED ELECTRONICS SYSTEMS 4224 W 7TH AVE EUGENE, OR 97402 PHONE: 541 - 485 -4456 FAX: Type of Use: COM Class of Work: ALT Type of Const: IIB Occupancy Grp: M Height: ft 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: Battery Calcs Provided: Yes Cut Sheets Required: Yes Total $776.26 Valuations: Required Items and Reports (Conditions) Sprinkler Valuation: 0 Residential Square Footage: 0 Fire Alarm Valuation: 80000 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 rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0100. You may obtain a copy of the rules or direct questions to OUNC by calling 503.246.6699 or 1.800.332.2344. Issued By: �•� 1 Permittee Signature: 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 Ir; 1-E- , , kaasi bt Thiilding Permit Application Fire Protection System HCE ® F012 OFFICE: USE ONLY City of Tigard /� Date /Bed I i Permit No.: 1 7 �2 O III 13125 SW Hall Blvd., Tigard, OR O 2 5 2009 Plan Revie. l/ ir '� C Phone: 503.639.4171 Fax: 503.M..19610. Date /B ani U � K T I G A R D Inspection Line: 503.639.4175 Ul i Y O F TIGARD Date Re° S ■ ®See Page 2 for Internet: www.tigard- or.gov B UILDING DIVISION Notified/Method: G Supplemental Information TYPE OF WORK REQUIRED DATA: l- 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 J�V Addition/alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the CATEGORY OF CONSTRUCTION work indicated on this application. Valuation: S ❑ I- and 2- family dwelling 4 Commercial /industrial ❑ Accessory building ❑ Multi- family Number of bedrooms: ❑ Master builder ❑ Other: Number of bathrooms: JOB SITE INFORMATION AND LOCATION Total number of floors: Job site address: 1 `-I (. 0D S.Lij i S e U DI t',1/4. P kwl j New dwelling area: square feet City/State/ZIP: i \ Cpl J� v R -3.'"--S ,f Garage /carport area: square feet Suite/bldg. /apt. no.: Project name: 11,1 e, L ` I ()p � t Covered porch area: square feet Cross street/directions to job site: y0 3 Deck area: square feet Other structure area: square feet REQUIRED DATA: COMMERCIAL -USE CHECKLIST .. Subdivision: I 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. QADNO4.0 f . l 1 A .( Y f P � �C t1 (Jl�l� /\, n� vy) Valuation: $ p SA �3 Existing building area: I 00 feet New building area: square feet • a PROPERTY OWNER I ❑ TENANT Number of stories: Name: \ Y ' J Vs , 1-..Y j ' )( )., Type of construction: * Address: 9 4 S5 �� ac .�� hd . Occupancy groups: pAe f anh `Qd City/State/ZIP ` 1 ��� 3q Existing: Phone: rn m `'7 I F.: 3ti L/' `7 g � 49 New: ❑ APPLICANT , I CONTACT PERSON NOTICE Business name: ` Te l \ QX 1 All contractors and subcontractors are required to be Contact name: � \Y l[ Jt V Q ( c) 1 ' , - � licensed with the Oregon Construction Contractors Board under ORS 701 and may be required to be licensed in the Address: L � rn V ► Ix (( C. , l ^ . I j. f 0 ( . jurisdiction in which work is being performed. If the City/ State/ZIP: l I ll lu 1 V 1 ' 1/ t ( -ig 1 �O applicant is exempt from licensing, the following reasons 2r1 1 (- 1 // O (� v i Fax: : 61/ �7 2 p J� /� �] apply: Phone: n54 /� �� / V C/� E -mail: 0XhOrn3 -id e-d ail r c-c w r I CONTRA OR BUILDING PERMIT FEES* ^ ' � Business name: L r,-� -e - GLA-LCi f' ICC, w) t L 4 ,) � " (Please refer to fee schedule) Permit fee: 51 S S0 Address: L/ ' / U � . "_I r City/ State/ZIP: nu l �/ /� l �7 v� State surcharge (12% of permit fee): t j m O LP / U FLS plan review (40% of permit fee): 0 Phone: ( �yh Lrd _ LA/6s Fax: ( ) (Due upon application.) 9b� t CCB lic.: Vl.Q 5 5g 9 7/ ! / (] Total permit fees: ', �3 t 5v, t i Authorized signature: a4.04.10 Amount received: This permit application expires if a permit is not obtained Print name: (v ac__ N, Nwl3 Date: 'b l q -09 within 180 days after it has been accepted as complete. * Fee methodology set by Tri -County Building Industry Service Board. I: \Building \Permits \FPS- PermitApp.doc 03 /23/06 440- 4613T(II /02 /COM/WEB) a City of Tigard: Fire Protection Permit Checklist Page 2 - Supplemental Information Describe work to be done: 1.) ❑ New 2.) Modification to sprinkler heads only: ❑ Addition El 1 -10 heads: No plan review required. ❑ Alteration ❑ 11+ heads: Plan review required. Repair Number of sprinkler heads: Additional description of work: C LaL,.a. ex , q ( .p ( ctiyyv Type of System (Complete A, B, C or D as applicable): A.) Commercial Sprinkler ❑ Wet ❑ Dry Additional Standpipes Information: Hazard Group Density Design Area K. Factor Sprinkler Project Valuation: $ B.) Type I - Hood Fire Suppression System Hood Project Valuation: I $ C.) Fire Alarm Submittal shall Battery Calculations �Y s include: Individual Component 'Yes Cut Sheets Fire Alarm Project Valuation: $ `A )) D.) Residential Sprinkler (Stand Alone System) Square Footage: Permit Fee: 0 to 2,000 $187.50 2,001 to 3,600 $232.50 3,601 to 7,200 $292.50 7,201 and greater $381.50 Sprinkler Project Square Footage: sq. ft. Fire Protection Permit Fees Project valuation subtotal (see A, B & C above): $ PO (I(� Permit fee based on project valuation (see fee schedule): $ �jL�j , Fj • Permit fee based on square footage (see D above): $ _ State Surcharge (12% of permit fee): $ LP \ ;la j Lo FLS Plan Review (40% of permit fee): $ 3t r a 'D TOTAL: $ Plan review requires a completed application and 2 sets of plans at submittal. Plan review fees are required at submittal. "New" fire protection systems require that plans bear the original seal of an Oregon licensed fire suppression engineer, or NICET level "3" technicians. P: \Home Depot \Replacement Program \ Oregon \ Tigard 4002 \ Does \FPS-PermitApp.dc2 q tom ; ..,. . r ?dO> G v4 CCB 165599 SYSTEMS, INC FIRE ALARM SYSTEM RECORD OF COMPLETION To be completed by the system Installation contractor at the time of system acceptance and approval. 1. PROTECTED PROPERTY INFORMATION Name of property: H avvve e w -' '1602. Address: 1430 5 Lk) >., ; 1; .- _r • (' 2. 2.3 Description of property: Occupancy type: Name of property representative: Address: Phone: Fax: E -mail: Authority having jurisdiction over this property: Phone: Fax: E -mail: 2. FIRE ALARM SYSTEM INSTALLATION, SERVICE, AND TESTING INFORMATION Installation contractor for this equipment: S� Address: P 0. - TO 'S 7 4 n 2- Phone: (S 4 q 9St;p Fax: E -mail: Service organization for this equipment: �G3 Address: P , 0. x 7095 C.N..� J OAK x °1.7 ti C5� Phone:( 9 9S (c) Fax: a E -mail: Location of as -built drawings: Location of historical test reports: Location of system operation and maintenance manuals: Mar."-e it A contract for test and inspection in accordance with NFPA standards is in effect as of Contracted testing company: Address: Phone: Fax: E - mail: Contract expires: Contract number: Frequency of routine inspections: 3. TYPE OF FIRE ALARM SYSTEM OR SERVICE n NFPA 72 Chapter Reference of System Type: 1 5 4b (` e Name of organization receiving alarm signals with phone numbers (if applicable): Alarm: Ai T Phone: t - %.,ew 4 z $ - 72,! Supervisory: g �T Phone: I - Z. - 9?4 - 7 2. S'4 Trouble: A 41' Phone: ( - - tin -7 2, 1'4 Entity to which alarms are retransmitted: ! (T 1 Phone: ! -1 60" 55 - y ?1 -72( tl Method of retransmission of alarms to that organization or location: <j Intercom CCVE - MATV Computer Cabling Fire Alarms • Nurse Call Telephone Systems • PAJSound Access Controls • Security Alarms P.O. Box. 708 • Eugene, OR 97440 -0708 • 541/485 -4456 • 541/688 -1478 (Fax) O y � M1 (£ 'y L1 ✓� CCB 165599 SYSTEMS, INC. 3. TYPE OF FIRE ALARM SYSTEM OR SERVICE (continued) If Chapter 8, note the means of transmission from the protected premises to the central station: 4 Digital alarm communicator ❑ McCulloh ❑ Multiplex ❑ 2 -way radio 0 1 -way radio ❑ N/A If Chapter 9, note the type of connection: ❑ Local energy 0 Shunt ❑ N/A 3.1 System Software //' Operating system (executive) software revision level: J O, 0 Site - specific software revision date: Revision completed by: 4. SIGNALING LINE CIRCUITS • Characteristics of signaling line circuits connect d o this system (see NFPA 72, Table 6.6.1): Quantity: Style: Class: f3 5. ALARM - INITIATING DEVICES AND CIRCUITS Characteristics of initiating device circuits connected to this system (see NFPA 72, Table 6.5): Quantity: Q Style: Y Class: 5.1 Manual Initiating Devices 1 Manual Pull Stations Number of manual pull stations: ! Type of devices: ' Addressable 0 Conventional ❑ Coded ❑ Transmitter 0 N/A 5.2 Automatic Initiating Devices 5.2.1 Area Smoke Detectors Number of smoke detectors: Type of coverage: ❑ Complete area ❑ Partial area s:I Nonrequired partial area ❑ N/A • Type of devices: ' Addressable 0 Conventional ❑ Coded ❑ Transmitter 0 N/A Type of smoke detector sensing technology: ❑ Ionization X Photoelectric 5.2.2 Duct Smoke Detectors Number of duct smoke detectors: Y Type of coverage: Type of devices: 0 Addressable ❑ Conventional ❑ Coded 0 Transmitter ❑ N/A Type of smoke detector sensing technology: ❑ Ionization ❑ Photoelectric 5.2.3 Heat Detectors Number of heat detectors: Type of coverage: ❑. Complete area ❑ Partial area Nonrequired partial area 0 N/A Type of devices: ❑ Addressable ❑ Conventional 0 Coded ❑ Transmitter ❑ N/A 5.2.4 Sprinkler Waterflow Detectors Number of waterflow detectors: �q Type of devices g Addressable ❑ Conventional ❑ Coded ❑ Transmitter ❑ N/A 5.2.5 Alarm Verification Number of devices subject to alarm verification: 12.1 Alarm verification on this system is: :g Enabled ❑ Disabled ❑ Set for seconds Intercom CCVE - MATV Computer Cabling Fire Alarms • Nurse Call Telephone Systems • PA/Sound Access Controls • Security Alarms P.O. Box 708 • Eugene, OR 97440 -0708 • 541/485 -4456 541/688 -1478 (Fax) /\ 4 O St_� . CCB 165599 SYSTEMS, INC 6. SUPERVISORY SIGNAL - INITIATING DEVICES AND CIRCUITS 6.1 Sprinkler System Number of valve supervisory switches: Type of devices: X Addressable 0 Conventional ❑ Coded ❑ Transmitter ❑ N/A 6.2 Fire Pump Type of fire pump: ❑ Electric ❑ Diesel Type of fire pump supervisory devices: ❑ Addressable ❑ Conventional ❑ Coded ❑ Transmitter ❑ N/A Fire Pump Functions Supervised ❑ Fire pump power ❑ Fire pump running ❑ Fire pump phase reversal ❑ Selector switch not in auto ❑ Engine or control panel trouble ❑ Low fuel Other: /VA 6.3 Engine- Driven Generator Type of generator supervisory devices: ❑ Addressable ❑ Conventional ❑ Coded ❑ Transmitter ❑ N/A ❑ Engine or control panel trouble ❑ Generator running ❑ Selector switch not in auto ❑ Low fuel Other: //A 7. ANNUNCIATORS 7.1 Annunciator 1 ❑ Local ;I Remote Type: Addressable ❑ Directory ❑ Graphic ❑ N/A Location: - - 6 7.2 Annunciator 2 ❑ Local ❑ Remote Type: ❑ Addressable ❑ Directory ❑ Graphic ❑ N/A Location: /10 Ji4 7.3 Annunciator 3 ❑ Local .❑ Remote Type: ❑ Addressable 0 Directory ❑ Graphic ❑ N/A Location: N/4 8. ALARM NOTIFICATION DEVICES AND CIRCUITS 8.1 Emergency Voice Alarm Service Number of single voice alarm channels: /v/, Number of multiple voice alarm channels: /VA Number of speakers: N Number of speaker zones: A1f4 8.2 Telephone Jacks Number of telephone jacks installed: A(/4 Number of telephone handsets stored on site: Type of telephone system installed: ❑ Electrically powered ❑ Sound powered Iffi N/A 8.3 Nonvoice Audible System Characteristics of notification device circuits connected to this system (see NFPA 72, Table 6.5): Quantity: Style: 1 Class: 5 Intercom CCVE - MATV Computer Cabling Fire Alarms Nurse Call Telephone Systems PA /Sound Access Controls • Security Alarms P.O. Box 708 • Eugene, OR 97440 -0708 • 541/485 -4456 • 541/688 -1478 (Fax) \ . . q `` ^ 4 tc..'�.r o CCB 165599 SYSTEMS, INC 8. ALARM NOTIFICATION DEVICES AND CIRCUITS (continued) 8.4 Types and Quantities of Nonvoice Notification Appliances Installed Bells: 1 With visual device: 0 Horns: C' With visual device: Chimes: With visual device: CS Bells: 21 With visual device: Visual devices without audible devices: to Other (describe): 9. EMERGENCY CONTROL FUNCTIONS ACTIVATED ❑ Hold -open door releasing devices ❑. Smoke management or smoke control ❑ Door unlocking ❑ Elevator recall '❑ Other 10. SYSTEM POWER SUPPLY 10.1 Primary Power Nominal voltage 12.0 \ A Amps Overcurrent protection: Type iY z. L r 3 Amps 2 Location (of primary supply panelboard): • ' IZ<- Disconnecting means location: 10.2 Seconds Power Location: FA Type: Nominal volta e: `Z-VDT (2 (a g Cur rent rating: Number of standby batteries: V. Amp our rating: (2.. R (15.1“ -) /2.-3( ,z¢a{- I�(12. 7A-H) Location of emergency generator: ^)/A Location of fuel storage: it) P1 Calculated capacity of secondary power to drive the system In standby mode: ay 11C€ . In alarm mode: �,•r�; �/, 11. RECORD OF SYSTEM INSTALLATION Fill out after all installation is complete and wiring has been checked for opens, shorts, ground faults, and improper branching, but before conducting operational acceptance tests. The system has been installed in accordance with the following NFPA standards: (Note any or all that apply.) NFPA 72 JiiI NFPA 70, National Electrical Code, Article 760 �t Manufacturer's published instructions 0- Other (please specify): AM-z. System deviations from referenced NFPA standards: N` Signed: Printed name: ► �� % r Date: /0 9 - � / �/ — D Organization: 1,t LL . Title: A . Phone: l_'�i•if 7 ‘8.5 -. 4 1 956 12. RECORD OF SYSTEM OPERATION All operational features and functions of this system were tested by or in the presence of the signer shown below, on the date shown below, and were found to be operating properly in accordance with the requirements of: NFPA 72 NFPA 70, National Electrical Code, Article 760 Manufacturer's published instructions A Other (please specify): Documentation in accordance with Inspection and Testing �F-orrmm (Figure 10.6.2.3) is attached Signed: Printed name -- t' 17- Date: 1 0- -a9 —0 Organization: Title: 2,44. Phone: Intercom CCVE - MATV Computer Cabling Fire Alarms • Nurse Call Telephone Systems • PA /Sound Access Controls •Security Alarms P.O. Box 708 • Eugene, OR 97440 -0708 • 541/485 -4456 • 541/688 -1478 (Fax) / ti 4 r� CCB 165599 SYSTEMS, INC. 13. CERTIFICATIONS AND APPROVALS 13.1 System Installation Contractor This system as specified herein has been installed and tested according to all NFPA standards cited herein. Signed. .tom, Printed name. --- 31/1. - 1 `I r Date: /O c� % —013 Org •zation: Title: 4', Phone gla S- 13.2 System Service Contractor 4, This system as specified herein has been installed and tested according to all NFPA standards cited herein. Signed: Printed nameip' A' f _ Date: /O 1c7 -- 0 Ci ,G Organization: T ,S . Title: Phone: ;/) 13.3 Central Station This system as specified herein will be monitored according to all NFPA standards cited herein. Signed,.., L lavl Printed name r Date: JO— ,3 ` r ^ p 9 Organization: Title: Phone:: y)) 13.4 Property Representative I accept this system as having been installed and tested to its specifications and all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: 13.5 Authority Having Jurisdiction I have witnessed a satisfactory acceptance test of this system and find it to be installed and operating properly in accordance with its approved plans and specifications, its approved sequence of operations, and with all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: Intercom CCVE - MATV Computer Cabling Fire Alarms • Nurse Call Telephone Systems • PA/Sound Access Controls • Security Alarms P.O. Box 708 • Eugene, OR 97440 -0708 • 541/485 -4456 • 541/688 -1478 (Fax) A o ti .iE -.S :c, CCB 165599 SYSTEMS, INC. INSPECTION AND TESTING FORM • DATE: ('— ,2.1 - TIME: 10 ; • SERVICE ORGANIZATION PROPERTY NAME (USER) Name: L E,S rr Name: � �p 4. 4 o ©2. Address: go 7d G Of..� 74a Address: 14%0C) .� tub: .w f doe `i7 Representative -P. llt �� Owner Contact: ,S+ - License No.• y(� L e .- A Telephone: Telephone: (..s 6 ySJ y 4 SC:2 MONITORING ENTITY APPROVING AGENCY Contact: / T Contact: /1H' Telephone: Telephone: MonitoringAccount Ref. No.: - H 1 7c,Si 7' is ` 1 TYPE TRANSMISSION SERVICE ❑ McCulloh ❑ Weekly ❑ Multiplex ❑ Monthly Digital ❑ Quarterly • ❑ Reverse Priority ❑ Semiannually ❑ RF X Annually ❑ Other (Specify) ❑ Other (Specify) Control Unit Manufacturer:_S. e.., -F . 11•40%..a Model No.: . 5© 1 ' Circuit Styles: C k.'5S ri Number of Circuits: 34 Software Rev.: ) Last Date System Had Any Service Performed: Vs)•Q2A. 10 —Cr‘t Last Date That Any Software or Configuration Was Revised: 0 — ALARM - INITIATING DEVICES AND CIRCUIT INFORMATION Quantity of Quantity of Devices Installed Circuit Style Devices Tested Manual Fire Alarm Boxes Ion Detectors 1 ( 1 Photo Detectors Ay Duct Detectors /11 / A- Heat Detectors G ( /c. r e (O Waterflow Switches C' 1 a.ss R Supervisory Switches 1 C / ^S,S fs' 1 Other (Specify): f &I Alarm verification feature is disabled • enabled X . Intercom CCVE - MATV Computer Cabling Fire Alarms • Nurse Call Telephone Systems • PA /Sound Access Controls • Security Alarms P.O. Box 708 • Eugene, OR 97440 -0708 • 541/485 -4456 • 541/688 -1478 (Fax) ti� 41 - n CCB 165599 - SYSTEMS, INC. ALARM NOTIFICATION APPLIANCES AND CIRCUIT INFORMATION Quantity of Quantity of Appliances Installed Circuit Style Appliances Tested Ups' R 11 Bells G 1 C I,n3t r5 Ca 1 Horns Chimes 5 Cf cs 5`j Strobes Speakers Other (Specify): No. of alarm notification appliance circuits: 2..3 Are circuits monitored for integrity? yd' Yes ❑ No SUPERVISORY SIGNAL - INITIATING DEVICES AND CIRCUIT INFORMATION Quantity of Quantity of De • • • s Installed Circuit Style Devices Tested a: ding Temp. Site Water Temp. Site Water Level Fire Pump Power Fire Pump Running Fire Pump Auto Position Fire Pump or Pump Controller Trouble Fire Pump Running Generator in Auto Position Generator or Controller Trouble Switch Transfer enerator Engine Running 0 : •r: SIGNALING LINE CIRCUITS Quantity and style of signaling line circuits to system (see NFPA 72, Table 6.6.1): Quantity Style(s) SYSTEM POWER SUPPLIES (a) Primary (Main): Nominal Voltage I Z VAS., Amps 20 x 2 Overcurrent Protection: Type g rr r f.. Amps 2.0 X 2 Location (of Primary Supply Panelboard): t - . `' - r , ,. \ Disconnecting Means Location: (b) Seconds, (Standby): Storage Battery: Amp -Hr Rating Z•y X IS A x 2 Calculated capacity in OSA 4 h Z, Amp -Hrs to operate system for hours Engine -driven generator dedicated to fire alarm system: � Location of fuel storage: il/ /! TYPE BATTERY ❑ Dry Cell ❑ Lead -Acid ❑ Nickel- Cadmium ❑ Other (Specify): f8, Sealed Lead -Acid (c) Emergency or standby system used as a backup to primary power supply, instead of using a secondary power supply: Emergency system described in NFPA 70, Article 700 Legally required standby described in NFPA 70, Article 701 Optional standby system described in NFPA 70, Article 702, which also meets the performance requirements of Article 700 or 701 Intercom CCVE - MATV Computer Cabling Fire Alarms • Nurse Call Telephone Systems • PA /Sound Access Controls • Security Alarms P.O. Box 708 • Eugene, OR 97440 -0708 • 541/485 -4456 • 541/688 -1478 (Fax) n wt` �r K //�� L may. 1 S- c yj f �z r ✓ CCB 165599 a 1fi5>aEt:` rfX is`'+ SYSTEMS, INC • PRIOR TO ANY TESTING NOTIFICATIONS ARE MADE Yes No Who Time Monitoring Entity K ❑ A DT I n ; 3�? .-■.., Building Occupants ,l'm ❑ Building Management jig ❑ 1 1 Other (Specify) ❑ ❑ AHJ Notified of Any Impairments ❑ ❑ SYSTEM TESTS AND INSPECTIONS TYPE ' Visual Functional Comments Control Unit 41 .6 0 Interface Equipment ,I pg Lamps/LEDs Al ,t Fuses tl III Primary Power Supply 10 I Trouble Signals S Disconnect Switches I& tt Ground -Fault Monitoring q Ja SECONDARY POWER TYPE Visual Functional !! ,, Comments Battery Condition _ILL v S -�v. /�_4(,� fx fyw. 37 Load Voltage /94.47-e Discharge Test A Charger Test ,fig Specific. Gravity TRANSIENT SUPPRESSORS ❑ REMOTE ANNUNCIATORS i( A d K NOTIFICATION APPLIANCES Audible jgf .5:3 Visible XI Speakers ❑ ❑ Voice Clarity ❑ INITIATING AND SUPERVISORY DEVICE TESTS AND INSPECTIONS Device Visual Functional Factory Measured Loc. & S/N Type Check Test Setting Setting Pass Fail ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Comments: ,S€& 1 1 S:C- 4....A'l Ct.' C'r) Intercom CCVE -MATV Computer Cabling Fire Alarms • Nurse Call Telephone Systems • PA /Sound Access Controls - Security Alarms P.O. Box 708 • Eugene, OR 97440 -0708 • 541/485 -4456 • 541/688 -1478 (Fax) INSPECTION REPORT SITE NAME: SITE ADDRESS: TYPE OF TEST: MAINTENANCE OTHER: DEVICE MAKE/MODEL/PART# FLR q LOCATION ZONE q DESCRIPTION _ TYPE 2/4 WIRE, RB, ETC. SEN CLN VIS TRB ALM PASS/ FAIL P � SDS05 — M'3 • 1 Fief' R�,,, (i• 12co A „� �,-t._ l > -ti-I 1 0 so E� -- P5 fi` 14 Pc.3 " i 1 1 OS °- Y &. • �, + I M(..3 b I ..�I ► e,se.R, y. o ©$ - Y 2. f ,-). L.2. ( X Pc,es g s-.1 1 e4 2 I PASS ---T-- k Fags � e4 31 x ■ ---1, r X > 2 . 5 j -- p4 . 32. X k R.-/.. r 1 1. z3 X X — ` - � ► -+ 33 �`' 12,.. 3 L i �,�,� , P rq3.•.� (- 5 -1. p zs , Si.) ( , 4�s1, (-....r-t_.. k x ��5 s pV S '�•r k P�_s s a R PGJ -L. SPECIAL INFORMATION: LEGEND: 0 NO ALARM RECEIVED NOTES: A 1 NO TRBL SIGNAL RECEIVED B 2 OTHER (SEE NOTES) C 3 UNABLE TO TEST (SEE NOTES) D J Ar rt n � ,Or a- 4 ti C CCB 165599 ,; s - SYSTEMS, INC EMERGENCY COMMUNICATIONS EQUIPMENT isual Functio• Comm nts Phone Set Phone Jacks J til Off -Hook Indicator Amplifier(s) 03I 181 Tone Generator(s) Call -in Signal System Performance )0 4 Device Simulated Visual Operation Operation COMB! ' TION SYSTEMS Fire Extingui sz onitoring Device/System ❑ 0 0 Carbon Monoxide Dete stem 0 0 0 (Specify) /t/44 0 0 INTERFACE EQUIPMENT / v (Specify) ^ //4 ❑ ❑ 0 (Specify) 0 ❑ ❑ (Specify) • 0 ❑ SPECIAL HAZARD SYSTEMS (Specify) N a - . ` ❑ ❑ (Specify) / � 0 r 0 (Specify) 0 0 0 Special Procedures: ��..� Comments: - r- ' SUPERVISING STATION MONITORING Yes No Time Comments Alarm Signal 0 . I CI:9 . Al 0 Alarm Restoration til 0 Trouble Signal A. 0 Trouble Signal Restoration Ikt 0 Supervisory Signal Ik 0 Supervisory Restoration A. 0 NOTIFICATIONS THAT TESTING IS COMPLETE Yes No Who Time Building Management A ❑ P ••• -.�.-•t f 1 1 : 30 Monitoring Agency 14 0 A A) I 11 y q Building Occupants 11` . Other (Specify) 0 0 / '� The following did not operate correctly: / J J - System restored to normal operation: Date: I 25 ) -09 Time: II:3 r , THIS TESTING WAS PERFORMED IN ACCORDANCE WITH APPLICABLE NFPA STANDARDS. Name of Inspector: (1: • -- f>,...,....._ . _ . , ra,-., Date: /i -- •—• Ciq Time: 3c //, 9 ,,a„„� Signature: r T — � — Name of Owns . R epresent. iv Ad. • e Date: /✓ z) p Time: /43d i r go, Signature: isaLA _ /,' iff inter om CCVE - MATV Computer Cabling Fire Alarms - Nurse Call Telephone Systems • PA /Sound Access Controls • Security Alarms P.O. Box 708 • Eugene, OR 97440 -0708 • 541/485 -4456 • 541/688 -1478 (Fax)