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Report (11) 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 y, Name of property: L i n c o\A. \O 1...0 C� l/)n ?o t,i C 16 O Address: t o 26,o 5G./ _(,-r-c t" T On.c? 3-2 2 3 Description of property: C9( ,.c,c,Occupancy type: .__.._.._ /344S-' �+ Name of property representative: 11 ur-c'\J f 4�e (� ` ....J C r✓ C Address: l° 2Z-V SGv G-rcCn 7,t- �Z4� AF - Ga..,. ..-1Z23 Phone: Fax: E-mail: Authority having jurisdiction over this property: Phone: Fax: E-mail: 2. INSTALLATION,SERVICE,AND TESTING CONTRACTOR INFORMATION Installation contractor for this equipment: �-'f`' \L,1 (_ ..c" r t L Address: I I L 0 ( C (? t \\ 11 (2 5 / ?2 v License or certification number: 2 I/?It 5 Phone:5(5 Z.ST-q fFP' Fax: E-mail: Service organization for this equipment: S ; ih be- r,n/).. (, \ Address: �3...s-- a .....S Lo R S ¢- -1 /i A �c d! { " ��, �1 ?j License or certification number: 113 3q1-1=A- Phone: 3'C73"3"ctO Fax: E-mail: 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. DESCRIPTION OF SYSTEM OR SERVICE El Fire alarm system(nonvoice) 12Fire alarm with in-building fire emergency voice alarm communication system(EVACS) El Mass notification system(MNS) El Combination system,with the following components: El Fire alarm ❑EVACS El MNS ❑Two-way,in-building,emergency communication system ❑Other(specify): NFPA 72, Fig. 10.18.2.1.1 (p. 1 of 12) Copyright 0 2009 National Fire Protection Association;for individual use,not to be commercially produced or distributed. 3. DESCRIPTION OF SYSTEM OR SERVICE(continued) NFPA 72 edition: Additional description of system(s): 3.1 Control Unit c ( I Manufacturer: J j me Lief,. (,-r r , l c, I J Model number: II/0 n u 3.2 Mass Notification System ❑This system does not incorporate an MNS 33..,2.11SS stem Type: PL‘-building MNS—combination ❑In-building MNS—stand-alone ❑Wide-area MNS ❑Distributed recipient MNS ❑Other(specify): 3.2.2 System Features: �d Combination fire alarm/MNS ❑MNS ACU only ❑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(HPSA)interface ❑In-building MNS to wide-area MNS interface ❑Other(specify): 3.3 System Documentation .3 CJ 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: fn c-,`_ 3.4 System Software ❑This system does not have alterable site-specific software. Operating system(executive)software revision level: 7•o l• a Site specific software revision date: 51 2`( 14 Revision completed by: 5t'v� Cr ,`A n e 11‘copy of the site-specific software is stored on site. Location: c,\ KO or r q t' 3.5 Off-Premises Signal Transmission ❑This system does not have off-premises transmission. Name of organization receiving alarm signals with phone numbers: Alarm: MQ ✓(A nG �R% n Phone: � C — 5 2/ Supervisory: I I Phone: I f Trouble: I Phone: I I Entity to which alarms are retransmitted: Phone: Method of retransmission: If Chapter 26,specify the means of transmission from the protected premises to the supervising station: 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;for individual use,not to be commercially produced or distributed. 4. CIRCUITS AND PATHWAYS 4.1 Signaling Line Pathways 4.1.1 Pathways Class Designations and Survivability r Pathways class: Survivability level: Quantity: (See NFPA 72,Sections 123 and 12.4) 4.1.2 Engine-Driven Generator Quantity: Description: 4.1.3 Device Power Pathways ❑No separate power pathways from the signaling line pathway N1 ❑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 N 4.2.1 Pathways Class Designations and Survivability Pathways class: Survivability level: Quantity: (See NFPA 72,Sections 12.3 and 12.4) 4.2.2 Pathways Utilizing Two or More Media Quantity: 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 itl-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 rr Pathways class: P Survivability level: Quantity: 1 (See NFPA 72,Sections 112.3 and 12.4) 4.3.2 Pathways Utilizing Two or More Media Quantity: Description: 4.3.3 Device Power Pathways ❑No separate power pathways from the notification appliance pathway {V ❑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 0112) Copyright©2009 National Fire Protection Association;for individual use,not to be commercially produced or distributed. 5. ALARM INITIATING DEVICES `n 5.1 Manual Initiating Devices 5.1.1 Manual Fire Alarm Boxes ❑This system does not have manual f e alarm boxes. Type and number of devices: Addressable: Conventional: Coded: . smitter: Other(specify): 5.1.2 Other Alarm Boxes ❑This system does n= 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 ❑Th. system does not have smoke detectors. Type and number of devices: Addressable: Conventional: Other(specify): Type of coverage: ❑Complete area ❑Partial area ❑Nonrequired ial area Other(specify): Type of smoke detector sensing technology: ❑Ionization ❑P •toelectric ❑Multicriteria ❑Aspirating ❑Beam Other(specify): 5.2.2 Duct Smoke Detectors ❑ • system does not have alarm-causing duct smoke detectors. Type and number of devices: Addressable: Co ventional: Other(specify): Type of coverage: Type of smoke detector sensing technology: ❑I•r ization ❑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: Addressa r e: Conventional: Type of coverage: 5.2.5 Heat Detectors ❑This system does not have heat detectors. Type and number of• •vices: Addressable: Conventional: Type of coverage: ❑Complete area ❑Partial area ❑Nonrequired partial area ❑Linear ❑Spot Type of heat det ctor sensing technology: ❑Fixed temperature ❑Rate-of-rise ❑Rate compensated NFPA 72. Fig. 10.18.2.1.1 (p.4 of 12) Copyright©2009 National Fire Protection Association;for individual use.not to be commercially produced or distributed. 5. ALARM INITIATING DEVICES(continued) I/ P) 5.2.6 Addressable Monitoring Modules ❑This system does not have monit 'ng modules. Number of devices: 5.2.7 Waterflow Alarm Devices ❑This system does not have aterflow alarm devices. Type and number of devices: Addressable: Conventional: Coded: Transmitter: 5.2.8 Alarm Verification ❑This system does not• corporate alarm verification. Number of devices subject to alarm verification: Alarm verification se or: seconds 5.2.9 Presignal ❑This syste does not incorporate pre-signal. Number of devices subject to presignal: Describe presignal functions: 5.2.10 Positive Alarm Sequence(PAS) • This system does not incorporate PAS. Describe PAS: 5.2.11 Other Initiating Devices ❑ s system does not have other initiating devices. Describe: 6. SUPERVISORY SIGNAL-INITIATING DEVICES 6.1 Sprinkler System Supervisory Devices ❑ ►' is system does not have sprinkler supervisory devices. Type and number of devices: Addressable: Conventi• al: Coded: Transmitter: Other(specify): 6.2 Fire Pump Description and Supervisory Devices ❑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) ❑This system does not have DSDs causing supervisory signals. Type and number of devices: Addre• .ble: Conventional: Other(specify): Type of coverage: Type of smoke detector sen ng technology: ❑Ionization ❑Photoelectric ❑Aspirating ❑Beam 6.4 Other Supervisory •evices ❑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;for individual use,not to be commercially produced or distributed. 7. MONITORED SYSTEMS 1 7.1 Engine-Driven Generator 111 This system does not have a generator. N It 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. Location 1: Location 2: Location 3: 9. ALARM NOTIFICATION APPLIANCES 9.1 In-Building Fire Emergency Voice Alarm Communication System ❑This system does not have a fire pump. 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: /- Other(describe): 9.3 Notification Appliance Power Extender Panels ❑This system does not have power extender panels. Quantity: Locations: NFPA 72, Fig. 10.18.2.1.1 (p. 6 of 12) Copyright©2009 National Fire Protection Association;for individual use,not to be commercially produced or distributed. 10. MASS NOTIFICATION CONTROLS,APPLIANCES,AND d1 CUITS L✓I This s y stem does nI have a n MNS. 10.1 MNS Local Operating Consoles Location I: 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-o ly visible appliances: Textual signs: Other(describe): Supervision class: 10 Special Hazard Notification This system does not have special suppression predischarge notific. on. ❑MNS systems DO NOT override notification appliances required o provide special suppression predischarge notification. 11. TWO-WAY EMERGENCY COMMUNICATION SYS EMS 11.1 Telephone System 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: El Electrica y powered ❑Sound powered 11.2 wo-Way Radio Communications Enh' cement System his system does not have a two-way rar o communications enhancement system. Percentage of area covered by two-way r s io 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 ocation: NFPA 72, Fig. 10.18.2.1.1 (p. 7 of 12) Copyright 0 2009 National Fire Protection Association;for individual use,not to be commercially produced or distributed. 11. TWO-WAY EMERGENCY COMMUNICATION SYSTEMS (continued) 11.3 Area of Refuge(Area of Rescue Assistance)Emergency Communications Systems I11�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: ININDays 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: K old-open door releasing devices ❑Smoke management Ll HVAC shutdown E F/S dampers Li Door unlocking R' evator recall ❑Fuel source shutdown ❑Extinguishing agent release m 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: )2.0%./4 c_. Control panel amps: /0 Overcurrent protection: Type: Vic_q ilk Amps: /0 Location(of primary supply panel board): 'ri m i,il 0 }n 2•o &e•-, Disconnecting means location: Z E L— I 13.1.2 Engine-Driven Generator Ilt'fhis 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;for individual use,not to be commercially produced or distributed. 13. SYSTEM POWER(continued) 13.1.3 Uninterruptible Power System LJ 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): 13.1.4 Batteries Location: 'E,«tiva,' (0,(Type: Nominal voltage: 24I Amp/hour rating: 3 3 Calculated capacity of batteries to drive the system: In standby mode(hours): Z`( ���5 In alarm mode(minutes): col r1..i [tteries are marked with date of manufacture 015-artery calculations are attached 13.2 In-Building Fire Emergency Voice Alarm Communication System or Mass Notification System El This system does not have an EVACS or MNS system. 13.2.1 Primary Power Input voltage of EVACS or MNS panel: `r�2 00C" lei • EVACS or MNS panel amps: Overcurrent protection: Type: Amps: Location(of primary supply panel board): 5 Disconnecting means location: 13.2.2 Engine-Driven Generator Ulcis system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: 13.2.3 Uninterruptible Power System Ck7iis 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): El Batteries are marked with date of manufacture ❑Battery calculations are attached NFPA 72, Fig. 10.18.2.1.1 (p.9 of 12) Copyright 0 2009 National Fire Protection Association;for individual use,not to be commercially produced or distributed. 13. SYSTEM POWER(continued) �,/ 13.3 Notification Appliance Power Extender Panels Lkl This system does not have power extender panels. 13.3.1 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: 13.3.2 Engine-Driven Generator 1 's system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: 13.3.3 Uninterruptible Power System !is 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): El 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 confucting otional acceptance tests. This is a: ❑New system aCJ Modification to an existing system Permit numbeiF?$7,0)y- 00075 e system has been installed in accordance with the following requirements:(Note any or all that apply.) NFPA 72,Edition: 9 Q 11 NFPA 70,National Electrical Code,Article 760,Edition: Manufacturer's published instructions Other(specify): System deviations from referenced NFPA standards: Signed: Printed name: Date: Organization: Title: Phone: NFPA 72, Fig. 10.18.2.1.1 (p. 10 of 12) Copyright©2009 National Fire Protection Association;for individual use,not to be commercially produced or distributed. 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: Rj 4loem�difications 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: VNFPA 72, Edition: 'Z (I �7 E NFPA 70,National Electrical Code,Article 760,Edition: L`1 i E 'wtl!anufacturer's published instructions Other(specify): ❑Individual device testing documentation[Inspection and Testing Form(Figure 14.6.2.4)is attached] Signed: 'IL Pfr---------- Printed name: /t w f a i` 1 1# c A-6 Date: 51,70 ji`1! Organization: Si wlp l-2-/‘ ''.rnt 1\ Title: 1 e cl, a., Phone: V 7 G 1-3-r 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: a_ge Date: .7307/7 Organization: CCrA apci4 C Title: et G�ySC1C( L.--- Phone: Se 3 —Z YO `30 j� 16.2 System Service Contractor: The undersigned has a service contract for this system in effect as of the date shown below. f Signed: d rinted name: g,a(j I r n dz Date: 5/3 t )/'/ Organization: S,„,/, c i,,,,,..< 11 Title: Te Jr, fi- Phone: 9 7--Cir"S"td mu 16.3 Supervising Station: This system,as specified herein,will be monitored according to all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: NFPA 72, Fig. 10.18.2.1.1 (p. 11 of 12) Copyright®2019 National Fire Protection Association;for individual use,not to be commercially produced or distributed. 16. CERTIFICATIONS AND APPROVALS (continued) 16.4 Property or Owner Representative: This system,as specified herein,will be monitored according to all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: 16.5 Authority Having Jurisdiction: I have witnessed a tisfactory acceptance test of this system and find it to be installed and operating properly in accordance w'/its approved plans and s.. ' cations,with its approved sequence of operations,and with all NFPA standar.: ' -. herei. r� - '-=• name: [ I Date: C2..'./V Signed: / ����_.-_-_._ _.�_.._._._..�� ,/ .__. _._..----._�._..__..___...._ Organ, ton: G.d ( Title: TS:T-- . _ Phone: ts_'7J8`2.6 / NFPA 72. Fig. 10.18.2.1.1 (p. 12 of 12) Copyright©2009 National Fire Protection Association;for individual use,not to be commercially produced or distributed.