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Permit CITY OF TIGARD FIRE PROTECTION SYSTEM PERMIT COMMUNITY DEVELOPMENT Permit #: FPS2011 -00019 TIGARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 03/04/2011 Parcel: 2S112AB00100 Jurisdiction: Tigard Site address: 7330 SW LANDMARK LN Project: TVT Die Casting and Manufacturing Subdivision: Lot: 0 Project Description: Fire alarm. Contractor: FIRST RESPONSE SYSTEMS INC Owner: SUMMIT PROPERTIES INC 4970 SW GRIFFITH DR #100 5550 SW MACADAM BLVD #205 BEAVERTON, OR 97005 PORTLAND, OR 97201 PHONE: 503 - 207 -5300 PHONE: FAX: 503 - 207 -5301 FEES Description Date Amount Specifics: Permit Fee - COM 03/04/2011 $134.48 12% State Surcharge - Building 03/04/2011 $16.14 Type of Use: COM Plan Review - Fire Life Safety - COM 02/15/2011 $53.79 Class of Work: ALT Type of Const: VB Info Process /Archiving - Lg Sheet (over 03/04/2011 $2.00 Occupancy Grp: B Height: ft 11x17) Stories: 1 Info Process /Archiving - Sm Sheet (up to 03/04/2011 $7.00 11x17) 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: Alarm Type: Automatic Pull Station Required: No Smoke Detectors Req: No Battery Calcs Provided: Yes Cut Sheets Required: Yes Total $213.41 Valuations: Required Items and Reports (Conditions) Sprinkler Valuation: $0.00 Residential Square Footage: 0 Fire Alarm Valuation: $5,500.00 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 rules are set forth in OAR 952 - 001 -0010 through OAR 952 - 001 -0090. You may obt.., a copy of the rules or direct questions to OU • calling 503.232.1987 or 1.800.332.2344. Issued By: Signature: I. 40 ` • , 6 Call 503.639. 1!0 1 a.m. for the next available inspe • n date. This permit card shall be kept in a conspicuous place on the job site unt completion of the prblect. Approved plans are required on the job site at the time of each inspection. Building Permit Application Fire Protection System e FOR OFFICE USE ONLY City of Tigard �j�� �0 \ D Received reim �'4>0'? : i ► L/ / ---(X10 1 3125 SW Hall Blvd., Tigar OR 97 Plan Review d 71 0 Phone: 503 F ax: 503. 598.1960 ` 3 1 G od DateB . inn �� Other Permit: Inspection Line: 503.639.417 ``CC �� S1 Date ReadyBy 3 Jug ® See Page 2 for C t GA K D Internet: www.tigard or.gov A ,, ` Notified/Metho j �� /� -1'� Supplemental Information * SPcli/t LJ ,: lh i�-Cgr-c- 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 ❑ Other: equipment, materials, labor, overhead, and the profit for the CATEGORY OF CONSTRUCTION work indicated on this application. ❑ 1- and 2- family dwelling ommercial/industrial es Valuation: $ CI 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: 7 330 SW 14 `'e- New dwelling area: square feet City/State/ZIP: / Ok Garage /carport area: square feet Suite/bldg. /apt. no.: Project name: TVT .,0 ;� J 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. Valuation: $ 1ns7a // // -I� a. alotrrn s 141 J Existing building area: square feet New building area: square feet ❑ PROPERTY OWNER ❑ TENANT Number of stories: Name: Type of construction: Address: Occupancy groups: uP Y !�' s: P City /State /ZIP: Existing: g Phone: ( ) Fax: ( ) New: ❑ APPLICANT ❑ 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: ( ) Fax:: ( ) E -mail: CONTRACTOR BUILDING PERMIT FEES* Business name: 1sT AN on S (Please refer to fee schedule) Permit fee: Address: 9 970 5111 1 1 t l 4 Z/ . City/State /ZIP: 8r (7 / — 9 7005 State surcharge (12% of permit fee): FLS plan review (40% of permit fee): 3 - , Phone: (f )2-0 7 sJ (.0 , I Fax: ) 2c, —53O / (Due upon application.) CCB lic.: (1/7/3 Total permit fees: Authorized signature ,, 4 Amount received: 5-3 . — 7 This permit application expires if a per it is not obtained Print name: J S� F Date: L /5� * within 180 days after it has been accepted as complete. s / Fee methodology set by Tri -County Building Industry Service Board. I:\ Building \Permits\FPS- PennitApp.doc 10 /01/09 440- 4613T(11 /02/COM/WEB) 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 ❑ 1 -10 heads: No plan review required. ❑ Alteration ❑ 11+ heads: Plan review required. ❑ Repair Number of sprinkler heads: Additional description of work: 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: $ C.) Fire Alarm Submittal shall Battery Calculations n Yes include: Individual Component . Yes Cut Sheets Fire Alarm Project Valuation: $ 4 509 D.) 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: $ Plan review requires a completed application and three (3) sets of plans at submittal. Plan review fees are required at submittal. 1: \Building \Permits \FPS - PermitApp.doc 01/20/2011 2 P SZeil- oaa 14-T FIRE ALARM AND EMERGENCY COMMUNICATION SYSTEM RECORD OF COMPLETION 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. 1. PROPERTY INFORMATION Name of property: M Die Casting Address: 7330 SW Landmark Ln, Portland, OR 97224 Description of property: manufacturing /offices Occupancy type: comm. Name of property representative: Jan Boettcher Address: same Phone: (503)639 -3850 Fax: E -mail: Authority having jurisdiction over this property: Portland Fire Phone: Fax: E -mail: 2. INSTALLATION, SERVICE, AND TESTING CONTRACTOR INFORMATION Installation contractor for this equipment: First Response Inc. Address: 4970 SW Griffith Park Dr., Beaverton, OR 97005 License or certification number: CCB #111713 Phone: 503 - 207 -5300 Fax: 503 - 207 -5301 E -mail: systems ©fr- inc.com Service organization for this equipment: same Address: License or certification number: Phone: Fax: E -mail: A contract for test and inspection in accordance with NFPA standards is in effect as of: this date Contracted testing company: same Address: Phone: Fax: E -mail: Contract expires: annually Contract number: Frequency of routine inspections: annually 3. DESCRIPTION OF SYSTEM OR SERVICE ® Fire alarm system (nonvoice) ❑ Fire alarm with in- building fire emergency voice alarm communication system (EVACS) ❑ Mass notification system (MNS) ❑ Combination system, with the following components: ❑ Fire alarm ❑ EVACS ❑ MNS ❑ Two -way, in- building, emergency communication system El Other (specify): NFPA 72, Fig. 10.18.2.1.1 (p. 1 0 Copyright © 2009 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. 3. DESCRIPTION OF SYSTEM OR SERVICE (continued) NFPA 72 edition: 2010 Additional description of system(s): full fire alarm install 3.1 Control Unit Manufacturer: Silent Knight Model number: 5700 3.2 Mass Notification System ® This system does not incorporate an MNS 3.2.1 System Type: ❑ In- building MNS combination ❑ In- building MNS— stand -alone ❑ Wide -area MNS ❑ Distributed recipient MNS ❑ Other (specify): .3.2.2 System Features: ❑ Combination fire alarm/MNS ❑ MNS autonomous control unit ❑ Wide -area MNS to regional national alerting interface ❑ Local operating console (LOC) Cl Direct recipient MNS (DRMNS) ❑ Wide -area MNS to DRMNS interface ❑ Wide -area MNS to high -power speaker array (HPSA) interface ❑ In- building MNS to wide -area MNS interface ❑ Other (specify): 3.3 System Documentation ® An owner's manual, a copy of the manufacturer's instructions, a written sequence of operation, and a copy of the numbered record drawings are stored on site. Location: panel 3.4 System Software ❑ This system does not have alterable site - specific software. Operating system (executive) software revision level: Site - specific software revision date: Revision completed by: ® A copy of the site - specific software is stored on site. Location: panel 3.5 Off - Premises Signal Transmission ❑ This system does not have off - premises transmission. Name of organization receiving alarm signals with phone numbers: Alarm: (watch Phone: 503 - 207 -5300 Supervisory: same Phone: Trouble: same Phone: Entity to which alarms are retransmitted: none Phone: Method of retransmission: If Chapter 26, specify the means of transmission from the protected premises to the supervising station: one way private radio If Chapter 27, specify the type of auxiliary alarm system: ❑ Local energy ❑ Shunt ❑ Wired ❑ Wireless • NFPA 72, Fig. 10.18.2.1.1 (p. 2 of 12) Copyright © 2009 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. 4. CIRCUITS AND PATHWAYS 4.1 Signaling Line Pathways 4.1.1 Pathways Class Designations and Survivability Pathways class: B Survivability level: 3 Quantity: 1 (See NFPA 72, Sections 12.3 and 12.4) 4.1.2 Pathways Utilizing Two or More Media Quantity: 0 Description: 4.1.3 Device Power Pathways ❑ No separate power pathways from the signaling line pathway ® Power pathways are separate but of the same pathway classification as the signaling line pathway ❑ Power pathways are separate and different classification from the signaling line pathway 4.1.4 Isolation Modules Quantity: none 4.2 Alarm Initiating Device Pathways 4.2.1 Pathways Class Designations and Survivability Pathways class: B Survivability level: 3 ......... Quantity: 4 (See NFPA 72, Sections 12.3 and 12.4) 4.2.2 Pathways Utilizing Two or More Media Quantity: 0 Description: 4.2.3 Device Power Pathways ❑ No separate power pathways from the initiating device pathway ® Power pathways are separate but of the same pathway classification as the initiating device pathway ❑ Power pathways are separate and different classification from the initiating device pathway 4.3 Non -Voice Audible System Pathways 4.3.1 Pathways Class Designations and Survivability Pathways class: B Survivability level: 3 Quantity: 2 _ _..... (See NFPA 72, Sections 12.3 and 12.4) 4.3.2 Pathways Utilizing Two or More Media Quantity: 0 Description: 4.3.3 Appliance Power Pathways ® No separate power pathways from the notification appliance pathway ❑ Power pathways are separate but of the same pathway classification as the notification appliance pathway ❑ Power pathways are separate and different classification from the notification appliance pathway NFPA 72, Fig. 10.18.2.1.1 (p. 3 of 12) • Copyright © 2009 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. 5. ALARM INITIATING DEVICES 5.1 Manual Initiating Devices 5.1.1 Manual Fire Alarm Boxes ❑ This system does not have manual fire alarm boxes. Type and number of devices: Addressable: 7 Conventional: Coded: Transmitter: Other (specify): 5.1.2 Other Alarm Boxes ® This system does not have other alarm boxes. Description: Type and number of devices: Addressable: Conventional: Coded: Transmitter: Other (specify): 5.2 Automatic Initiating Devices 5.2.1 Smoke Detectors ❑ This system does not have smoke detectors. Type and number of devices: Addressable: 6 Conventional: Other (specify): Type of coverage: ® Complete area ❑ Partial area ❑ Nonrequired partial area Other (specify): Type of smoke detector sensing technology: ❑ Ionization 0 Photoelectric ❑ Multicriteria ❑ Aspirating ❑ Beam Other (specify): _ ....._._,_ 5.2.2 Duct Smoke Detectors ® This system does not have alarm - causing duct smoke detectors. Type and number of devices: Addressable: Conventional: Other (specify): Type of coverage: Type of smoke detector sensing technology: ❑ Ionization ❑ Photoelectric ❑ Aspirating ❑ Beam 5.2.3 Radiant Energy (Flame) Detectors ® This system does not have radiant energy detectors. Type and number of devices: Addressable: Conventional: Other (specify): Type of coverage: 5.2.4 Gas Detectors ® This system does not have gas detectors. Type of detector(s): Number of devices: Addressable: Conventional: Type of coverage: 5.2.5 Heat Detectors ❑ This system does not have heat detectors. Type and number of devices: Addressable: Conventional: 15 Type of coverage: ® Complete area ❑ Partial area ❑ Nonrequired partial area ❑ Linear ❑ Spot Type of heat detector sensing technology: ® Fixed temperature ❑ Rate -of -rise ❑ Rate compensated • NFPA 72, Fig. 10.18.2.1.1 (p. 4 of 12) Copyright 0 2009 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. 5. ALARM INITIATING DEVICES (continued) 5.2.6 Addressable Monitoring Modules N This system does not have monitoring modules. Number of devices: 5.2.7 Waterflow Alarm Devices N This system does not have waterflow alarm devices. Type and number of devices: Addressable: Conventional: Coded: Transmitter: 5.2.8 Alarm Verification N This system does not incorporate alarm verification. Number of devices subject to alarm verification: Alarm verification set for seconds 5.2.9 Presignal N This system does not incorporate pre - signal. Number of devices subject to presignal: Describe presignal functions: 5.2.10 Positive Alarm Sequence (PAS) N This system does not incorporate PAS. Describe PAS: 5.2.11 Other Initiating Devices N This system does not have other initiating devices. Describe: 6. SUPERVISORY SIGNAL - INITIATING DEVICES 6.1 Sprinkler System Supervisory Devices N This system does not have sprinkler supervisory devices. . Type and number of devices: Addressable: Conventional: Coded: Transmitter: ........... .............. Other (specify): 6.2 Fire Pump Description and Supervisory Devices N This system does not have a fire pump. Type fire pump: ❑ Electric pump ❑ Engine Type and number of devices: Addressable: Conventional: Coded: Transmitter: Other (specify): 6.2.1 Fire Pump Functions Supervised ❑ Power ❑ Running ❑ Phase reversal ❑ Selector switch not in auto ❑ Engine or control panel trouble ❑ Low fuel Other (specify): 6.3 Duct Smoke Detectors (DSDs) N This system does not have DSDs causing supervisory signals. Type and number of devices: Addressable: Conventional: Other (specify): Type of coverage: Type of smoke detector sensing technology: ❑ Ionization ❑ Photoelectric ❑ Aspirating ❑ Beam 6.4 Other Supervisory Devices N This system does not have other supervisory devices. Describe: NFPA 72, Fig. 10.18.2.1,1 (p. 5 of 12) Copyright © 2009 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. 7. MONITORED SYSTEMS 7.1 Engine- Driven Generator ® This system does not have a generator. 7.1.1 Generator Functions Supervised ❑ Engine or control panel trouble ❑ Generator running ❑ Selector switch not in auto ❑ Low fuel ❑ Other (specify): 7.2 Special Hazard Suppression Systems ❑ This system does not monitor special hazard systems. Description of special hazard system(s): 7.3 Other Monitoring Systems ❑ This system does not monitor other systems. Description of special hazard system(s): 8. ANNUNCIATORS ❑ This system does not have annunciators. 8.1 Location and Description of Annunciators Location 1: Lobby entrance Location 2: Location 3: 9. ALARM NOTIFICATION APPLIANCES 9.1 In- Building Fire Emergency Voice Alarm Communication System 0 This system does not have an EVACS. Number of single voice alarm channels: Number of multiple voice alarm channels: Number of speakers: Number of speaker circuits: Location of amplification and sound - processing equipment: Location of paging microphone stations: Location 1: Location 2: • Location 3: 9.2 Nonvoice Notification Appliances ❑ This system does not have nonvoice notification appliances. Horns: With visible: 13 Bells: With visible: Chimes: With visible: Visible only: 2 Other (describe): 9.3 Notification Appliance Power Extender Panels ❑ This system does not have power extender panels. Quantity: 1 Locations: at panel in lunch room NFPA 72, Fig. 10.18.2.1.1 (p. 6 of 12) Copyright 02009 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. 10. MASS NOTIFICATION CONTROLS, APPLIANCES, AND CIRCUITS ® This system does not have an MNS. 10.1 MNS Local Operating Consoles Location 1: Location 2: Location 3: 10.2 High -Power Speaker Arrays Number of HPSA speaker initiation zones: Location 1: Location 2: Location 3: 10.3 Mass Notification Devices Combination fire alarm/MNS visible appliances: MNS -only visible appliances: Textual signs: Other (describe): Supervision class: 10.3.1 Special Hazard Notification ❑ This system does not have special suppression predischarge notification. ❑ MNS systems DO NOT override notification appliances required to provide special suppression predischarge notification. 11. TWO - WAY EMERGENCY COMMUNICATION SYSTEMS 11.1 Telephone System ® This system does not have a two -way telephone system. Number of telephone jacks installed: Number of warden stations installed: Number of telephone handsets stored on site: Type of telephone system installed: ❑ Electrically powered ❑ Sound powered 11.2 Two -Way Radio Communications Enhancement System ® This system does not have a two -way radio communications enhancement system. Percentage of area covered by two -way radio service: Critical areas: % General building areas: Amplification component locations: Inbound signal strength: dBm Outbound signal strength: dBm Donor antenna isolation is: dB above the signal booster gain Radio frequencies covered: Radio system monitor panel location: NFPA 72, Fig. 10.18.2.1.1 (p. 7 of 12) Copyright © 2009 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. • 11. TWO -WAY EMERGENCY COMMUNICATION SYSTEMS (continued) 11.3 Area of Refuge (Area of Rescue Assistance) Emergency Communications Systems ® This system does not have an area of refuge (area of rescue assistance) emergency communications system. Number of stations: Location of central control point: Days and hours when central control point is attended: Location of alternate control point: Days and hours when alternate control point is attended: 11.4 Elevator Emergency Communications Systems ® This system does not have an elevator emergency communications system. Number of elevators with stations: Location of central control point: Days and hours when central control point is attended: Location of alternate control point: Days and hours when alternate control point is attended: 11.5 Other Two -Way Communication Systems Describe: 12. CONTROL FUNCTIONS This system activates the following control fuctions: ❑ Hold -open door releasing devices ❑ Smoke management ❑ 1-IVAC shutdown ❑ F/S dampers ❑ Door unlocking ❑ Elevator recall ❑ Fuel source shutdown ❑ Extinguishing agent release Cl Elevator shunt trip ❑ Mass notification system override of fire alarm notification appliances Other (specify): 12.1 Addressable Control Modules ❑ This system does not have control modules. Number of devices: Other (specify): 13. SYSTEM POWER 13.1 Control Unit 13.1.1 Primary Power Input voltage of control panel: 120 Control panel amps: 20 Overcurrent protection: Type: breaker Amps: Location (of primary supply panel board): next to panel Disconnecting means location: same 13.1.2 Engine- Driven Generator ® This system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: NFPA 72, Fig. 10.18.2.1.1 (p. 8 of 12) Copyright © 2009 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. • 13. SYSTEM POWER (continued) 13.1.3 Y Uninterruptible Power System ® This system does not have a UPS. P Y Equipment powered by a UPS system: Location of UPS system: Calculated capacity of UPS batteries to drive the system components connected to it: In standby mode (hours): In alarm mode (minutes): 13.1.4 Batteries Location: panel Type: sla Nominal voltage: 24 Am /hour rating: 8 P g� Calculated capacity of batteries to drive the system: In standby mode (hours): 24 In alarm mode (minutes): 5 ® Batteries are marked with date of manufacture ® Battery calculations are attached 13.2 In- Building Fire Emergency Voice Alarm Communication System or Mass Notification System ® This system does not have an EVACS or MNS system. 13.2.1 Primary Power Input voltage of EVACS or MNS panel: EVACS or MNS panel amps: Overcurrent protection: Type: Amps: Location (of primary supply panel board): Disconnecting means location: 13.2.2 Engine- Driven Generator ❑ This system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: 13.2.3 Uninterruptible Power System ❑ This system does not have a UPS. Equipment powered by a UPS system: Location of UPS system: Calculated capacity of UPS batteries to drive the system components connected to it: In standby mode (hours): In alarm mode (minutes): 13.2.4 Batteries Location: Type: Nominal voltage: Amp /hour rating: Calculated capacity of batteries to drive the system: In standby mode (hours): In alarm mode (minutes): ❑ Batteries are marked with date of manufacture El Battery calculations are attached NFPA 72, Fig. 10.18.2.1.1 (p. 9 of 12) Copyright © 2009 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. 13. SYSTEM POWER (continued) 13.3 Notification Appliance Power Extender Panels ❑ This system does not have power extender panels. 13.3.1 Primary Power Input voltage of power extender panel(s): 120 Power extender panel amps: 20 Overcurrent protection: Type: breaker Amps: 20 Location (of primary supply panel board): next to panels Disconnecting means location: 13.3.2 Engine- Driven Generator ❑ This system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: 13.3.3 Uninterruptible Power System ❑ This system does not have a UPS. Equipment powered by a UPS system: Location of UPS system: Calculated capacity of UPS batteries to drive the system components connected to it: In standby mode (hours): In alarm mode (minutes): 13.3.4 Batteries Location: Type: Nominal voltage: Amp /hour rating: Calculated capacity of batteries to drive the system: In standby mode (hours): In alarm mode (minutes): ❑ Batteries are marked with date of manufacture ❑ Battery calculations are attached 14. 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. This is a: ® New system ❑ Modification to an existing system Permit number: FPS2011 -00019 The system has been installed in accordance with the following requirements: (Note any or all that apply.) Z NFPA 72, Edition: 2010 ® NFPA 70, National Electrical Code, Article 760, Edition: 2008 ® Manufacturer's published instructions Other (specify): System deviations from referenced NFPA standards: Signed: Printed name: Kevin Bohn Date: 3/4/11 Organization: First Response Inc. Title: Technician Phone: 503 - 207 -5300 NFPA 72, Fig. 10.18.2.1.1 (p. 10 of 12) Copyright © 2009 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. 15. RECORD OF SYSTEM OPERATIONAL ACCEPTANCE TEST ® New system 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 for the following: ❑ Modifications to an existing system All newly modified operational features and functions of the 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 the following: ® NFPA 72, Edition: 2010 ® NFPA 70, National Electrical Code, Article 760, Edition: 2008 ® Manufacturer's published instructions Other (specify): ❑ Individual device testing documentation [Inspection and Testing Form (Figure 14.6.2.4) is attached] Signed: Printed name: Kevin Bohn Date: 3/4/11 Organization: First Response Inc. Title: Technician Phone: 503 - 207 -5300 16. CERTIFICATIONS AND APPROVALS 16.1 System Installation Contractor: • This system, as specified herein, has been installed and tested according to all NFPA standards cited herein. • Signed: / Printed name: Kevin Bohn Date: 3/4/11 Organization: First Response Title: Technician Phone: 503 - 207 -5300 16.2 System Service Contractor: The undersigned has a service contract for this system in effect as of the date shown below. Signed: same Printed name: Date: Organization: Title: Phone: • 16.3 Supervising Station: This system, as specified herein, will be monitored according to all NFPA standards cited herein. Signed: same Printed name: Date: Organization: (watch Title: Phone: NFPA 72, Fig. 10,18.2.1.1 (p. 11 of 12) Copyright © 2009 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. • 16. CERTIFICATIONS AND APPROVALS (continued) 16.4 Property or Owner 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: 16.5 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, with its approved sequence of operations, and with all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: NFPA 72, Fig. 10.18.2.1.1 (p. 12 of 12) Copyright © 2009 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. •