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Report FI� Za� Z- 0 1z 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: _1 ii V 6 O �6fLoo� C, Address: (90 � 9 30 (p 3 (oACNOAMl!`S L� D) Description of property: Q T /c»4 0 (1u)s- 0 Occupancy type: Name of property representative: Address: Phone: Fax: E -mail: Authority having jurisdiction over this property: Phone: Fax: E -mail: 2. INSTALLATION, SERVICE, AND TESTING G CONTRACTOR INFORMATION / � y \ N Installation contractor for this equipment: ,, `` G am �G �1I� & l a it� \vim[, ((10- 1'i GT 10 • Address: I ; 1 b ( FIR- S r 0ax6 CA - O (L, License or certification number: ) 0 HSI() C_(.5 Phone: O3 - bS1 ' S 1 SS" Fax: E -mail: Service organization for this equipment: Address: S it W\, 9 License or certification number: Phone: Fax: E -mail: • A contract for test and inspection in accordance with NFPA standards is in effect as of: Contracted testing company: c_iko.A % S 11- Address: Phone: Fax: E -mail: Contract expires: Contract number: Frequency of routine inspections: 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 ❑ Other (specify): • 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: W `P Additional description of system(s): 3.1 Control Unit Manufacturer: c 1 /'S Model number: vAs Li 3.2 Mass Notification System is 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) ❑ Direct recipient MNS (DRMNS) ❑ Wide -area MNS to DRMNS interface ❑ Wide -area MNS to high -power speaker array (1-IPSA) interface ❑ In- building MNS to wide -area MNS interface ❑ Other (specify): 3.3 System Documentation n 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: Vi�c• A • G • Q 3.4 System Software �'I'his 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: 3.5 Off - Premises Signal Transmission ❑ This system does not have off - premises transmission. Name of organization receiving alarm signals with phone numbers: �J�� Alarm: A4 r' - ` ` Phone: %11 t/" ( o - i i q I t Supervisory: Phone: It Trouble: Phone: Entity to which alarms are retransmitted: 1, v 1 f t • (2 Phone: Method of retransmission: If Chapter 26, specify the means of transmission from the protected premises to the supervising station: 1p., (2-1)%\o If Chapter 27, specify the type of auxiliary alarm system: ❑ Local energy ❑ Shunt ❑ Wired ❑ Wireless Copyright 0 2009 National Fire Protection Assodation. This form may be copied for individual use other than for resale. It may not be copied for cornmerdal sale or distribution. 4. CIRCUITS AND PATHWAYS 4.1 Signaling Line Pathways 4.1.1 Pathways Class Designations and Survivability n Pathways class: Survivability level: Quantity: L- (See NFPA 72, Sections 12.3 and 12.4) 4.1.2 Pathways Utilizing Two or More Media Quantity: Description: 4.13 Device Power Pathways o 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: 4.2 Alarm Initiating Device Pathways 4.2.1 Pathways Class Designations and Survivability Pathways class: Survivability level: Quantity: 2 (See NFPA 72, Sections 12.3 and 12.4) 4.2.2 Pathways Utilizing Two or More Media Quantity: Description: 4.23 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 43 Non -Voice Audible System Pathways 43.1 Pathways Class Designations and Survivability Pathways class: Survivability level: Quantity: 2„ (See NFPA 72, Sections 12.3 and 12.4) 43.2 Pathways Utilizing Two or More Media Quantity: Description: 433 Hance 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 copyright to 2009 National Are Protection Association. This form may be copied for Individual use other than for resale. It may not be coped 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: Conventional: 1 Coded: Transmitter: Other (specify): ��+ 5.1.2 Other Alarm Boxes Cf 71tts 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 nts system does not have smoke detectors. Type and number of devices: Addressable: Conventional: Other (specify): Type of coverage: ❑ Complete area r al area ❑ Nonrequired partial area Other (specify): Type of smoke detector sensing technology: ❑ Ionization ErPlrotoelectric ❑ Multicriteria ❑ Aspirating ❑ Beam Other (specify): 5.2.2 Duct Smoke Detectors is 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 5.23 Radiant Energy (Flame) Detectors 2T i system does not have radiant energy detectors. Type and number of devices: Addressable: Conventional: Other (specify): Type of coverage: 5.2.4 Gas Detectors s system does not have gas detectors. Type of detector(s): Number of devices: Addressable: Conventional: Type of coverage: 5.2.5 Heat Detectors is system does not have heat detectors. Type and number of devices: Addressable: Conventional: 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 Copyright m 2009 National Fue Protection Association. This form may be copied for Individual use other than for resale. It may not be copied for cornmerdal sale or distribution. 5. ALARM INITIATING DEVICES (continued) 5.2.6 Addressable Monitoring Modules ❑ This system does not have monitoring modules. Number of devices: 5.2.7 Waterflow Alarm Devices ❑ This system does not have waterflow alarm devices. Type and number of devices: Addressable: Conventional: 1 Coded: Transmitter 5.2.8 Alarm Verification ' `` tus system does not incorporate alarm verification. Number of devices subject to alarm verification: Alarm verification set for seconds 5.2.9 Presignal ,1is system does not incorporate pre- signal. Number of devices subject to presignal: Describe presignal functions: 5.2.10 Positive Alarm Sequence (PAS) 0" 1 s system does not incorporate PAS. Describe PAS: 5.2.11 Other Initiating Devices 0<s system does not have other initiating devices. Describe: 6. SUPERVISORY SIGNAL - INITIATING DEVICES 6.1 Sprinkler System Supervisory Devices ❑ This system does not have sprinkler supervisory devices. Type and number of devices: Addressable: Conventional: I Coded: Transmitter: Other (specify): 6.2 Fire Pump Description and Supervisory Devices Is 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) s 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 `0' fystem does not have other supervisory devices. Describe: Copyright ©2009 National Fre 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 is 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 is system does not monitor special hazard systems. Description of special hazard system(s): 7.3 Other Monitoring Systems 12i<system does not monitor other systems. Description of special hazard system(s): ���� 8. ANNUNCIATORS [7»s system does not have annunciators. 8.1 Location and Description of Annunciators Location 1: Location 2: Location 3: 9. ALARM NOTIFICATION APPLIANCES 9.1 In- Building Fire Emergency Voice Alarm Communication System Er<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: Bells: With visible: Chimes: With visible: Visible only: 2 Other (describe): 93 Notification Appliance Power Extender Panels is system does not have power extender panels. Quantity: Locations: 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 Igs 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: 103 Mass Notification Devices Combination fire alarm/MNS visible appliances: MNS -only visible appliances: Textual signs: Other (describe): Supervision class: 103.1 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 Ef"I his 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 o-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: 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. 11. TWO -WAY EMERGENCY COMMUNICATION SYSTEMS (continued) 113 Area of Refuge (Area of Rescue Assistance) Emergency Communications Systems is 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 IE 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 ❑ HVAC shutdown ❑ F/S dampers ❑ Door unlocking ❑ Elevator recall ❑ Fuel source shutdown ❑ Extinguishing agent release ❑ Elevator shunt trip ❑ Mass notification system override of fire alarm notification appliances Other (specify): 12.1 Addressable Control Modules Ze<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: 1(,` 41\L 'k'' Control panel amps: S Overcurrent protection: Type: eA Amps: ZO Location (of primary supply panel board): 1 721,0(,j -7 \•\O,A Q V Disconnecting means location: 'Qj‘A) 6- rG%k• , \O 2 V\ ovd Pit is a' 13.1.2 Engine - Driven Generator feirs system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: 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. 13. SYSTEM POWER (continued) 13.13 Uninterruptible Power System fiefg<tem 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): 13.1.4 Batteries .� •' Location: f-, a, p, Type: 5 � Nominal voltage: `W DI Amp/hour rating: Calculated capacity of batteries to drive the system: In stand y mode (hours): 2 In alarm mode (minutes): atteries are marked with date of manufacture ttery calculations are attached 13.2 uilding Fire Emergency Voice Alarm Communication System or Mass Notification System is 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 s 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 ❑ Battery calculations are attached 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. 13. SYSTEM POWER (continued) 133 Notification Appliance Power Extender Panels ®'IT►is system does not have power extender panels. 133.1 Primary Power Input voltage of power extender panel(s): Power extender panel amps: Overcurrent protection: Type: Amps: Location (of primary supply panel board): Disconnecting means location: // 133.2 Engine - Driven Generator 1 is system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: Er‘ system Uninterruptible Power System $ Ittis 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): 133.4 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 befor conducting operational acceptance tests. This is a: ew system ❑ Modification to an existing system Permit number: The sy tern has been installed in accordance with the following requirements: (Note any or all that apply.) NFP 72, Edition: -0 10 FPA 70, National Electrical Code, Article 760, Edition: 2 fj p Manufacturer's published instructions Other (specify): System deviations m referenced NFPA standards: r 014 Signed: />; Printed name: SLAT " TQW W - Date: \Z \lo Organization: .5.�. , Tide: IK.,11 Phone: er \ - 21-1 ' C( '1f0 Copyright ® 2009 National Are Protection Association. This form may be copied for Individual use other than for resale. It may not be copied for commercial sale or distibution. 15. RECORD OF SYSTEM OPERATIONAL ACCEPTANCE TEST w 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: Wig 72, Edition: if) I 0 NFPA 70, National Electrical Code, Article 760, Edition: 20 % {2Ma published instructions Other (specify): ❑ Individual de e testing documentation [Inspection and Testing Form (Figure 14.6.2.4) is attached] Signed: //) \I. Printed name: �` A Date: CZ \Q Z vl?— Organizationn: 'r- • S . V. \ • Title: `tom Phone: q 1 Z1 i 16. CERTIFICATIONS AND APPROVALS `p, r 16.1 System Installation Contractor: S h k % This system, as specified herein, has been installed and tested according to all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: 16.2 System Service Contractor: M� 1114 � The undersigned has a service contract for this system in effect as of the date shown below. Signed: Printed name: Date: Organization: Title: h Phone: 163 Supervising Station: 4 44 %Ptlibk.r. / This system, as specified herein, will be monitored according to all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: Copyright C 2009 National Fire Protection Association. This form may be copied for Individual use other than for resale. It may not be coped for onmmerdai 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: 165 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: 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. _ o ( S.