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Permit n CITY OF TIGARD FIRE PROTECTION SYSTEM PERMIT 1111 2' = COMMUNITY DEVELOPMENT Permit #: FPS2011 -00087 T1 G.ARD 13125 SW Hall Blvd., Tigard OR 97223 503.718.2439 Date Issued: 07/22/2011 Parcel: 2S110AA00300 Jurisdiction: Tigard Site address: 14145 SW 105TH AVE Project: Pacific Health and Rehabilitation Center Subdivision: Lot: Project Description: Fire alarm Contractor: HI TECH SYSTEMS INC A CORPORATION OF WASHI Owner: TIGARD INVESTMENT GROUP LLC 512 NW CARTY RD BY EYRING REALTY INC RIDGEFIELD, WA 98642 1777 N CALIFORNIA BLVD #300 WALNUT CREEK, CA 94596 PHONE: 360- 887 -7062 PHONE: FAX: 360- 887 -7065 FEES Description Date Amount Specifics: Permit Fee - COM 07/06/2011 $209.80 12% State Surcharge - Building 07/06/2011 $25.18 Type of Use: COM Plan Review - Fire Life Safety - COM 07/06/2011 $83.92 Class of Work: ALT Type of Const: VB Info Process /Archiving - Lg Sheet (over 07/06/2011 $4.00 Occupancy Grp: I -1 Height: ft 11x17) Stories: 1 Info Process /Archiving - Sm Sheet (up to 07/06/2011 $16.50 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: Yes Alarm Type: Automatic Pull Station Required: Yes Smoke Detectors Req: Yes Battery Calcs Provided: Yes Cut Sheets Required: Yes Total $339.40 Valuations: Required Items and Reports (Conditions) Sprinkler Valuation: $0.00 Residential Square Footage: 0 Fire Alarm Valuation: $13,000.00 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 No . on - . Tho e rules are set forth in OAR 952 - 001 -0010 through OAR 952- 001 -0090. You may obtain a copy of the rules or dire questions to OUNC calli g 03.232.1987 or 1.800.332.2344. Iss ed By: / Permittee Signature: ard746.. Call 503.639.4175 by 7:00 a.m. for the next available inspecti 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. Building Permit Application , � " E � � D • (...,V r. Fire Protection System FOR OFFICE USE ONLY liPli City of Tigard DateB 7 Mira 7,7 Permit No. je, At/r//06). 13125 SW Hall Blvd., Tigard, 97223 g Plan Review ► 2 Phone: 503.718.2439 Fax: 503.598.19611 0 6 2011 Date/B : 41KAI Other Permit: TIGARD Inspection Line: 503.639.4175 Date Ready F.'" Juris: ® See Page 2 for Internet: www.tigard- or.gov CITY OF TIGARD Notified/Method./ Supplemental Information • IS DIVISION v/ F / ELF v60/4 SSG DI TYPE O REQUIRED DATA: 1- AND 2- FAMILY DWELLING ❑ New construction ❑ Demolition Permit fees* are based on the value of the work performed. Indicate the value (rotnded to the nearest dollar) of all - Addition/alteration/replacement ❑ Other: equipment, materials, labor, overhead, and the profit for the CATEGORY OF CONSTRUCTION work indicated on this application. ❑ 1- and 2- family dwelling ❑ Commercial /industrial Valuation: $ i < 3 00 cD ❑ Accessory building ❑ Multi- family Number of bedrooms: ❑ Master builder ,Other: k ea.,1 In (...-- c f � Number of bathrooms: JOB SITE INFORMATION AND LOCATION Total number of floors: Job site address: I L, 1 L 5 \..) 1 US ti A3+ New dwelling area: square feet City /State /ZIP: T* (.: ,,,,,, c -,,,,. / 0 (:)\ et - 7 )2_,Li Garage /carport area: square feet Suite/bldg. /apt. no.: J J Project name: Net t!I- Hu{ . o b C Covered porch area square feet Cross street/directions to job site: Deck area: square feet ■ L \ONn ckt., C7\y h wy C1 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 (rotrided to the nearest dollar) of all equipment, materials, labor, overhead, and the profit for the DESCRIPTION OF WORK work indicated on this application. C\ p....-p 1 ih..L- r C� ckN c s M i avve.1 Y_\ � Valuation: $ p r t" Existing building area square feet i prr,�..v\-- New building area: square feet ❑ PROPERTY OWNER ❑ TENANT Number of stories: Name: Type of construction: Address: Occupancy groups: City/State /ZIP: Existing: 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: 'I', , J 6 C rfi� Permit fee: (Please refer to feeschedute) `� Address: , 12 N tiJ Carly I? /State /ZIP: `` State surcharge (12% of permit fee): City/State/ZIP: R ` kD e `-' % " " °, 6 1 56 6 LI FLS plan review (40% ofpermit fee): Phone: (2,G0 ) ES?- '76(22— Fax: (3.O ) $ ?7- J() ( (Due upon application.) CCB lic.: i _ )(00 Total permit fees: Authorized signature: Amount received: T his permit application expires if a permit is not obtained Print name: „ c Ile2 Date: //6/ 3 ' within 180 days after it has been accepted as complete. * Fee methodology set by Tri -County Building Industry Service Board. t\Building\Permits \FPS- PermitApp.doc 02/01/2011 440- 4613T(l1 /02/COM/WEn) 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 El 11+ heads: Plan review required. El Repair Number of sprinkler heads: Additional description of work: Type of System (Complete A, B, C or D as applicable): A.) Commercial Sprinkler ❑ Wet El 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 El Yes include: Individual Component El Yes Cut Sheets Fire Alarm Project Valuation: $ 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. I: \Boil ding \Permits \FPS- PermitApp.doc 02/01/2011 2 08/02/2011 12:54 3608877065 HI TECH SYSTEM PAGE 01/03 AUG 0 2 2011 CITY OF TIGARD ( ppipT ry I c T7r `-� ' FOLLC (Ame( ae)-60-0A1 Q t' -(2_QT 30-6 .9 . darpWr ; f1� T'�. D(* Ors R4 Pi ysr 5 arry b7 4 r , 3V-D eco-r-yrN 4 PS RDI (9(3csi 3100r f0~1 a- dry 512 NW Carty Rd., Ridgefield. WA 98042 + ph: 360/887 -7062 fax: 360/887 -7065 08/02/2011 12:54 3608877065 HI TECH SYSTEM PAGE 02/03 PROJECT SUBSTANTIAL COMPLETION NOTICE Nursing Homes, Assisted Living Facilities and Residential Care Facilities INSTRUCTIONS: • Complete and forward this report approximately three weeks prior to receiving an Occupancy Permit from the Authority Having Jurisdiction. • Coordinate the actual inspection date and time with staff at Facilities Planning and Safety. • Patient/Resident occupancy should not take place until the Site Inspection has been completed, all Inspection items resolved, a Project Building Approval is issued from Facilities Planning and Safety and appropriate documents are completed for Seniors & People with Disabilities. For further information, please call 503- 373 -7201. Copies should be provided and forwarded. as follows: For ALL projects, FORWARD ONE COPY TO: For ALL projects, FORWARD ONE COPY TO: Pamela Triplett The City, County or State Building FACILITIES PLANNING & SAFETY Codes Agency which issued the Oregon Health Authority - Public Health Building Permit for the project. 880 Winter Street, NE l �� Salem, OR 97301 F% , 'o3 r Set it it FAX: 503 -373 -0313 For NURSING HOMES For RESIDENTIAL CARE FACILITIES FORWARD ONE COPY TO: FORWARD ONE COPY TO: Dave Allm Residential Care Program LICENSING & QUALITY OF CARE LICENSING & QUALITY OF CARE Seniors & People with Disabilities Seniors & People with Disabilities 500 Summer Street, NE, (E -13) 500 Summer Street, NE, (E -13) Salem. OR 97310 • Salem OR 97310 FAX: 503- 378 -8966 FAX: 503- 378-8966 . For ASSISTED LIVING FACILITIES FORWARD ONE COPY TO THE STATE FIRE FORWARD ONE COPY TO: MARSHAL'S OFFICE: Assisted Liviii Program Gayle Johnson LICENSING & Q G a UALITY OF CARE FIRE & LIFE SAFETY SERVICE UNIT Seniors & People with Disabilities Office of State Fire Marshal 500 Summer Street, NE, (E -13) 4760 Portland Road, NE Salem OR 97310 Salem OR. 97305 FAX: 503-378-8966 ,FAX: 503.373 -1825 PLANS REVIEW #: PIS #i I I FACILITY NAME: � _,._.,. ' PROJECT DESCRIPTION:. '- ��,� - �n �► `-`� `�'- ADDRESS: - 11 FACILITY CONTACT PERSON: -- � ` . J ADDRESS: it-)_,51--/ r 1 d n7 TELEPHONE NO: 3 o.3 (7 "` )) WI FAX No: - •3 - .ro ;.2 0 " ! A O I E -MAIL ADDRESS: „--._ DESIRED INSPECTION DATE: e 1'�'ti -- .Tg—® (A) ;114 d1.j'T `1 . ' ° m`^'� 0". EXPECTED OCCUPANCY DATE: At .. - 4_0 • I:\Hcalth 8crvioea \3.AT TH8 WALL- DOCUMCNTS\3- MISCEL.LANSOUS 6, 2i, OR\( 6)- ProjSubstComrl- NursIlomcs 'RcaidFacAsstdLivrnc- Word.doo 08/02/2011 12:54 3608877065 HI TECH SYSTEM PAGE 03/03 NOTICE OF CONSTRUCTION PLANS APPROVAL FACILITIES, PLANNING & SAFETY OREGON HEALTH AUTIIOR.ITY - PUBLIC HEALTH DIVISION Office of Community Health. and Health Planning (For projects to be licensed by Health Care Regulation & Quality Improvement or Seniors and People with Disabilities) FACILITY: PACIFIC GARDENS HEALTH & REHAB PR#: 11 -67 PROJECT: REPLACE CLASS 13 FIRE AL SYSiTy: ADDRESS: 14145 SW 105 ST. TIGARD OREGON 97224 This Notice is intended to inform the project sponsor, architect and licensing agency that construction plans for the above noted project have been reviewed and approved by Facilities Planning & Safety. Further agency comments, if any, regarding the proposed methods for corrections are noted below. Approval of submitted plans is not an approval of omissions or oversights by this agency or of non - compliance with any applicable rules, regulations or codes. Please find attached. a copy of our .Proiect Substantial Completion ,Notice form which needs to be completed and sent to those agencies listed on the form. This needs to be done approxi.matel.y three weeks prior to the intended occupancy of the project area. ii GENCY COMMENTS, IF ANY, REGARDING PLAN REVIEW RESPONSES AND PROPOSED PLAN OF CORRECTIONS: There were no .lan review comments. I June 22, 20111 Approve y: cy E. Renfrow Date FACILITIES PLANNING & SAFETY cc: /Don Legge Dan Jones, Oregon State Deputy Fire Marshal Mark Vand.orrmelen, City of Tigard Building Official Dave Allm, SENIORS & PEOPLE WITT DISABILITIES ;q il C ,'TV 50V 6 1:11-lealth Services \Pacific Clardcns 1 -11th & Rehab - Tigard\ L1-67 Rep= Class B Fire Alalrm Systcm \6.22,11 MER- ConstPlanAPPrvt 1111- 67 -docx I - 1 Y 1 t (., r l '�j '. ,}t ;, �, `r "Y �� ll 4, f . • 54ste m1 Cic,„/ L✓4 5 / G. 17 F r • f lPS ' Zc / I - INSPECTION AND TESTING FORM DALE: r-- ' 7S - 1( • 0008 ,IME: .C)U . SERVICE O PROP ERTY NAME (USER) Naurc: T.L. .DCC in S :'S ! Cpy1 5 Name IJGLC - c I'C (i- „d Address: S i t tt/ lox/ C 6 t Address: / r.,I r t/ S S L" /0% A c_ Representative: .J L cr'7r .wr: /L Owner Contact: License Nn.: C / CO 12 '/ 3 A6 Telephone: 7 cicphonc: 3 6 0 -- . fr i -� 06 2 ____ MONITORING ENTRY APPROVING AGENCY Contact: C 5 G G tl -- -- ) / t G Contact: Tart.' • _ _kS k- .. Y k kfr II ( el . micpimnc: J.tunliming Account Rel. No.: 8 1 TYPE TRANSMISSION SERVICE • U McCulluh U \Vcckly U Multiplex U Monthly Digital U Quarterly U Rcvcrsc Pliorily U Semiannually U Ikr tit Annuall U Other (Specify) % Other (Specify) A// lit/ L✓1 S % r^ I i . Panel Manufacturer: ;lend % k . L.ti` _ Model No.: S' 20 Circuit Styles: A 00v. cSc. - t Number of Circuits: / .'/... C 10 6j . Software Rev.: Last Dale System had Any Service Performed: ”' 7- Z 5 1 . Last Date that Any Software or Configuration Was Revised: 7 — 2 5 - / ALARM - INITIATING DEVICES AND CIRCUIT INFORMATION Quantity Circuit Style A OD Manual Stations - -� Ion Detectors '7 3 4 Do Photo Detectors Duct Detectors 7 fDU heat Detectors I _ 4 01) Waterflow Switches I 4 [)1.`) Supervisory Switches I A no o Other (Specify): k; T tic n (NEPA Inspection and Tcslinp I of 4) 512 NW Carty Rd., Ridgefield, WA 98642 ph: 3601887 - 7062 fax: 3601887 - 7065 Figure 7 -5.21 (Cor dinucd) ALARM NOTIFICATION APPLIANCES AND CIRCUIT INFORMATION Quantity Circuit Style Bells horns 16 t3 •a csf S7ro6 s 4 13 Strobes Speakers Other (Specify): No. of alarm indicating circuits: t/r Arc circuits supervised? KYcs 0 No • SUPERVISORY SIGNAL - INITIATING DEVICES AND CIRCUIT INFORMATION • Quantity • Circuit Style Building Temp. c Water Temp. Site Waier Level Fire Pump Power Fire Pump Running Fire Pump Auto Position Fete Pump or Pump Controller Trouble Fire Pump Running Generator In Auto Position Generator or Controller Trouble Switch Transfer Generator Engine Running Ott ter. SIGNALING LINE CIRCUITS Quantity and style (Scc NITA 72. Table 3 -6) of signaling linc circuits connected to system: Quantity / Stylc(s) SYSTEM POWER SUPPLIES a. Primary (Maw): Nominal Voltage / L ( , Amps 20 Ovcrcuncni Protection: Type i3 ,-ca rocs . Amps 7 0 Location (Panel Number): e P1 / Disconnccling Means Location: b. Secondary (Standby): 2- 1 Z f. Storage Daltcty: Amp -I Ir. Rating 1 All Calculated capacity to operate system. in hours: 24 60 Engine- driven generator dedicated to fire alarm system: Location of fuel storage: TYPE BATTERY U Dry Ccll O Nickel- Cadmium l,Scalcd Lead -Acid ❑ Lead-Acid U Other (Specify): c- Emergency or standby system used as a backup to primary power supply, instead of using a secondary power supply: Emergency system described in NIPA 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. oI 4) (NA A Inspection and Testing 1999 Edition 512 NW Carty Rd., Ridgefield, WA 98642 ph: 3601887 fax: 3601557 PRIORTO ANY TESTING. NOTIFICATIONS ARE MADE Yes No Who Time Monitoring Entity Ut U C 7 ,/`", -r r � : 00 Building Occupants 0- U S 7< q- Oc Building Management A- ❑ S7Q-Fc-- 6 /61 0 Other (Specify) )et ❑ Al II (Notified) of Any Impairments U U SYSTEM TESTS AND INSPECTIONS TYPE Visual Functional Comments Control Panel III ❑ Interface Fri. -jQ U Lamps/LEDS III ❑ ` Fuses . , ca I9inrary Power Supply ❑ Trouble Signals '0 U Disconnect Switcldcs 16 ❑ Ground -Fault Monitoring .I U SECONDARY POWER . TYPE Visual Functional Comments Battery Condition Vi load Voltage ia Discharge Test S4 Charger Test 1 Specific Gravity p • TRANSIENT SUPPRESSORS ❑ • • REMOTE ANNUNCIATORS 4 NOTIFICATION APPUANCES Audible 9 VI Visual $ 'h Speakers ❑ 0 Voice Clarify 0 INITIATING AND SUPERVISORY DEVICE TESTS AND INSPECTIONS Device Visual Functional Factory Meas. Loc. & SIN Type Check Test Setting Selling Pass Fail W Pt/ t I A 16 ❑ '7 .3 5 „icr 9 111- 44 ❑ 1 ti ❑ • i ee III Q. EX._ ❑ 1 k�i.. ( kover 4;i1 4 4. 15f ❑ Couuucnts: • (NFPA Inspection and Testing 3 at 4) 1999 Edition 512 NW Carty Rd., Ridgefield, WA 98642 ph: 3601887 -7062 fax: 3601887 -7065 Figure 7 -5.2.Z (Cuulinurd) • EMERGENCY COMMUNICATIONS EQUIPMENT Visual Functional Comments Phone Set ❑ ❑ Phone Jacks ❑ ❑ Off-Hook Indicator U ❑ Amplificr(s) U ❑ Tone Geueratou(s) U ❑ Call -in Signal ❑ • System Per fnnnancc ❑ ❑ Device Simulated Vi . Operation Operation INTERFACE EQUIPMENT (Specify) U ❑ (] (Specify) U ❑ 0 (Specify) ❑ ❑ U SPECIAL I IAZARD SYSTEMS (Specify) ❑ ❑ U . (Specify) U ❑ U (Specify) U ❑ U Special Piocedures: • b Columculs: • • • ON/OFF PREMISES MONITORING Yes No Time Comments Alarm Signal '9 ❑ q:0/) Alarm Rcsloral 40 ❑ qYl [) Trouble Signal lel ❑ q:0o Supervisory Signal 14 LI gOO Supervisory Rcsloral 'EL ❑ Gj,�0 NOTIFICATIONS THAT TESTING IS COMPLETE Yes No Who Time Building Management Vi ❑ S7` F 12-7 3 Monitoring Agency lig ❑ S Tc„J I Z 16 Building Occupants 1i ❑ Outer (Specify) 6- ❑ The following did not operate correctly: T ■ • u k / System restored to normal operation: Dale: 7- Z S- / / Time: F - U 0 THIS TESTING WAS PERFORMEDIN ACCORDANCE WITH APPLICABLE NFPA STANDARDS. Name of Inspector: ..-- S • ?, In .- ..., Date: 7- 2 S - j ( Time: I UU Signature: — a.-.-X-- Name of Owner or Represent Dale: Time: • Signature: (NITA Inspection and Testing 4 of 4) 1999 Edition • • 512 NW Carty Rd., Ridgefield, WA 98642 p h: 360/887 -7062 fax: 360/887 -7065 National Fire Alarm Code - Certificate of Completion Name of Protected Property: Pa, �i c � s Permit #: Physical Address: /L/ /L/ ! S ; , r / D Suite #: Rep. Of Protected Property (name /phone): SO3 4 3e1 - Authority Having Jurisdiction: Address/Phone Number: I. Type(s) of System or Service: _NFPA 72, Chapter 3 —Local If alarm is transmitted to location(s) off premises, list where received: C S!7 - ! 6 3 fr/4- /7 5 mitIFPA 72, Chapter 3— Emergency Voice /Alarm Service Quantity of Voice /Alarm Channels: Single: Multiple: Quantity of Speakers Installed:' Quantity of Speaker Zones: ,,Q Quantity of Telephones or Telephone Jacks Included in this System: t NFPA, Chapter 4— Auxiliary Indicate Type of Connection: Local Energy Shunt (rallel Telephone Location and Telephone Number for Receipt of Signals: CSM / itkk - 3irk, l�yij X NFPA 72, Chapter 4— Remote Station Alarm: yc I Supervisory: ye S _NFPA 72, Chapter 4— Proprietary If alarms are retransmitted to public fire service communications center or others, indicate location and telephone number of the organization receiving the alarm: C S!" I /;Ifrk 1 &u-1 7 cs el Indicate how alarm is retransmitted: r f�va� f-.r.,bi to,. C ot.ATY C� 5 4 3-52-0-135 NFPA 72, Chapter 4— Central Station The Prime Contractor: Central Station Location: Security Central — Statesville, NC Means of Transmission of Signals from the Protected Premise to the Central Station: McCulloh Multiplex One -Way Radio Two -Way Radio c igital Alarm Communicator Other: Means of transmission of alarms to the public fire service communications center: 1. C0.47- r T 1� 2. System Location: Organization Name/Phone Representative Name/Phone Installer T rest , S :'S7'c, 340' k1 7 - 7662 Supplier A j I' Service Organization pi j_ 'rec ,. 5 ;�57 -c'-' t' Physical Address �r�s S USAv Location of Record (As- Built) Drawings: Site. 0" ,4 r Fcr z p Location of Owners Manuals: Site. 4-T Fc,.cP Location of Test Reports: Site. X 4r FC ( n 2. Certification of System Installation: (Fill out after installation is complete and wiring checked for opens, shorts, ground faults, and improper branching, but prior to conducting operational acceptance tests.) This system has been installed in accordance with the NFPA standards as listed below, was inspected by ik/57 n on r ] 2 5 - ! l � includes the devices listed below and has been in service since -ZS -/ l NFPA 72, Chapters l) c (. (circle all that apply) NFPA 70, National Electrical Code, Article 760 Manufacturer's Instructions Other (specify): j -7 Signed: "eed....e.:, ✓ " � Date: ! — � S " r1 Organization: 141T Mc t'i 5 5'S 7�i"� 3. Certification of System Operation: All Operational features and functions of this system were tested by % to on *] — 2 5 -II And found to be operating properly in accordance with the requirements of: NFPA 72, Chapters j ) (J Q (circle all that apply) NFPA 70, National Electrical Code, Article 760 •f Manufacturer's Instructions Other (specify): Signed: Vied.Z. 4 Date 2 5 - ( 1 Organization: WZ T S `r5 4. Alarm Initiating Devices and Circuits (Use blanks to indicate quantity of devices.): MANUAL a) L4 _ Manual Stations AUTOMATIC a) '7 3 _ Smoke Detectors _ Ion XPhoto b) Duct Detectors _ Ion _ Photo c) 7 _ Heat Detectors _ FT _ RR X FT/RR _ RC d) f _ Sprinkler Water Flow Switches e) _ Other (list): k;7Cln /-dui.( Page2of3 Form r Physical Address 5. Supervisory Signal Initiating Devices and Circuits (Use blanks to indicate quantity of devices.): Sprinkler System: I Electric Fire Pump: +V/A- r a) I , Tamper Switches i e) _ Fire Pump Power b) Building Temperature Points f) _ Fire Pump Running c) . Site Water Temperature Points g) _ Phase Reversal d) Site Water Supply Level Points Engine -Driven Fire Pump: NA_ Engine -Driven Generator: 4/74. h) _ Selector in Auto Position k) Selector in Auto Position i) _ Engine or Control Panel trouble 1) _ Control Panel Trouble j) _ Fire Pump Running m) Transfer Switches n) Engine Running Other Supervisory Function(s) (specify):_ 6. Alarm Notification Appliances and Circuits: 'J Quantity of indicating appliance circuits connected to the system:_ vl Types and Quantities of Alarm Indicating Appliances Installed: a) / Cin: /S Teo b5 b) . Speakers c) . Horns d) Horn/Strobes e) . Speaker /Strobes f) C _ Strobes 7. Signaling Line Circuits: Quantity and Style (See NFPA 72, Table 3 -6.1) of signaling line circuits connected to system: Quantity: /4 Style:J3 8. System Power Supplies: a) Primary (Main): Nominal Voltage:, 1 Current Rating:_ Z 0 Overcurrent Protection: Type:_ (a(-c -c.- le-c-,.- Current Rating:_ Z 0 Location:_rj P' -vwi/ 13�e-..-14e.- 10 b) Secondary (Standby): . Storage Battery: Amp Hour Rating: 7 12 At 11 . Calculated Capacity to Drive System, in hours: "A__24 _60 Engine- Driven Generator Dedicated to Fire Alarm System: • Location of fuel Storage:_ c) Emergency or Standby System used as back up to Primary Power Supply, instead of using a Secondary Power Supply: Emergency System Described in NFPA 70, Article 700 }Legally Required Standby System described in NFPA 70, Article 701 _ Optional Standby System described in NFPA 70, Article 702, which also meets the performance requirements of Articles 700 and 701. 9. System Software: Operating System Software Revision Level(s): Application Software Revision Level(s): Revision Completed By: a c,-5>',1n Date: r7- 2 $ _I I Signature: �� f � Firm: I — Te GI, 5 Ype."-- . Page 3 of 3 Form 7