Report r
SYSTEM RECORD OF COMPLETION
This form is 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.
Form Completion Date: 7/16/2015 Supplemental Pages Attached: N/A
1. PROPERTY INFORMATION
Name of property: Lincoln 3-suite 305
Address: 10220 SW GREENBURG RD.TIGARD,OR 97223
Description of property: B OCC.
Name of property representative:
Address:
Phone: Fax: E-mail:
2. INSTALLATION, SERVICE,TESTING,AND MONITORING INFORMATION
Installation contractor. CAPITAL ELECTRIC
Address: 11401 NE MARX ST.PORTLAND OR 97220
Phone: 503-255-9488 Fax: E-mail:
Service organization: SIMPLEXGRINNELL
Address: 6305 SW Rosewood St.,Lake Oswego,OR 97035
Phone: 503-683-9000 Fax: E-mail:
Testing organization: N/A
Address:
Phone: Fax: E-mail:
Effective date for test and inspection contract:
Monitoring organization: ADVANTAGE PROTECTION
Address: N/A
Phone: 888-295-5298 Fax: E-mail:
Account number: 5221 Phone line 1: Phone line 2:
Means of transmission: SDACT
Entity to which alarms are retransmitted: n/a Phone:
3. DOCUMENTATION
On-site location of the required record documents and site-specific software: FACP
4. DESCRIPTION OF SYSTEM OR SERVICE
This is a: ❑New system ®Modification to existing system Permit number: 1P S 2015- 00 O 9?
NFPA 72 edition: 2012
4.1 Control Unit
Manufacturer: SIMPLEX Model number: 41000
4.2 Software and Firmware
Firmware revision number: 14.01.07
4.3 Alarm Verification ®This system does not incorporate alarm verification.
Number of devices subject to alarm verification: Alarm verification set for seconds
Copyright 0 2012 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.
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SYSTEM RECORD OF COMPLETION(continued)
5. SYSTEM POWER
5.1 Control Unit
5.1.1 Primary Power
Input voltage of control panel: 120 VAC Control panel amps: 10A
Overcurrent protection: Type: CKT.BREAKER Amps: 20A
Branch circuit disconnecting means location: 1 FL ELECTRIC RM Number: 1 L2-73
5.1.2 Secondary Power
Type of secondary power: BATTERY
Location,if remote from the plant: FACP
Calculated capacity of secondary power to drive the system:
In standby mode(hours): 24hrs In alarm mode(minutes): 5mins
5.2 Control Unit
® This system does not have power extender panels
❑ Power extender panels are listed on supplementary sheet A
6. CIRCUITS AND PATHWAYS
Pathway Type Dual Media Pathway Separate Pathway Class Survivability Level
Signaling Line 1 B
Device Power N/A
Initiating Device N/A
Notification Appliance 1 B
Other(specify):
7. REMOTE ANNUNCIATORS
Type Location
8. INITIATING DEVICES
Addressable or
Type Quantity Conventional Alarm or Supervisory Sensing Technology
Manual Pull Stations 0
Smoke Detectors 0
Duct Smoke Detectors 0
Heat Detectors 0
Gas Detectors 0
Waterflow Switches 0
Tamper Switches 0
Copyright 6 2012 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.
SYSTEM RECORD OF COMPLETION(continued)
9. NOTIFICATION APPLIANCES
Type Quantity Description
Audible
Visible 2 CEIL.MT STROBE
Combination Audible and Visible 3 CEIL. MT HORN/STROBE
10. SYSTEM CONTROL FUNCTIONS
Type Quantity
Hold-Open Door Releasing Devices 0
HVAC Shutdown 0
Fire/Smoke Dampers 0
Door Unlocking 1
Elevator Recall 0
Elevator Shunt Trip 0
11. INTERCONNECTED SYSTEMS
® This system does not have interconnected systems.
❑ Interconnected systems are listed on supplementary sheet .
12. CERTIFICATION AND APPROVALS
12.1 System Installation Contractor
This system as pecified h in has been installed according to all NFPA standards cited herein.
Signed: 1/7 Printed name:40w,,, f evet47_- Date: V/tit(
Organization: C.7;041/ 66c-hie- Title: e Lc_}nc i e.-' Phone: ,o3-255- ?'/t
12.2 System Operational Test
This system as specified herein has tested according to all NFPA standards cited herein.
Signed: l/2LQ./ti gO .th tef ei.. Printed name: BRIAN BOWLSBY Date: 7/16/15
Organization: SIMPLEXGRINNELL Title: TECH REP Phone: 503-683-9000
12.3 Acceptance Test
Date and time of acceptance test:
Installing contractor representative:
Testing contractor representative:
Property representative:
AHJ representative:
Copyright 0 2012 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.