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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: 9/3/2015 Supplemental Pages Attached:
1. PROPERTY INFORMATION
Name of property: Epic Land Solutions
Address: 10300 SW Greenburg Road,Tigard,OR 97223
Description of property: B-Business
Name of property representative:
Address:
Phone: Fax: E-mail:
2. INSTALLATION, SERVICE,TESTING,AND MONITORING INFORMATION
Installation contractor: Capitol Electric
Address: 11401 NE Marx Street,Portland,OR 97220
Phone: (503)255-9488 Fax: E-mail:
Service organization: SimplexGrinnell
Address: 6305 SW Rosewood,Suite A,Lake Oswego,OR 97035
Phone: (503)683-9000 Fax: E-mail:
Testing organization:
Address:
Phone: Fax: E-mail:
Effective date for test and inspection contract:
Monitoring organization:
Address:
Phone: Fax: E-mail:
Account number: Phone line 1: Phone line 2:
Means of transmission:
Entity to which alarms are retransmitted: Phone:
3. DOCUMENTATION
On-site location of the required record documents and site-specific software:
4. DESCRIPTION OF SYSTEM OR SERVICE
This is a: ❑ New system ®Modification to existing system Permit number:
NFPA 72 edition:
4.1 Control Unit
Manufacturer: Simplex Model number: 4100U
4.2 Software and Firmware
Firmware revision number: Rev 12.05.05
4.3 Alarm Verification ®This system does not incorporate alarm verification.
Number of devices subject to alarm verification: Alarm verification set for seconds
Copyright m 2012 National Fire Protection Assodation.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 l nit
5.1.1 Primary Power
Input voltage of control panel: 120 VAC Control panel amps: 3 amps
Overcurrent protection: Type: Circuit Breaker Amps: 20 amp
Branch circuit disconnecting means location: Number:
5.1.2 Secondary Power
Type of secondary power: 2 Batteries in panel
Location,if remote from the plant:
Calculated capacity of secondary power to drive the system:
In standby mode(hours): In alarm mode(minutes):
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
Device Power
Initiating Device
Notification Appliance
Other(specify):
7. REMOTE ANNUNCIATORS
Type Location
8. INITIATING DEVICES
Addressable or
Type Quantity Conventional Alarm or Supervisory Sensing Technology
Manual Pull Stations
Smoke Detectors
Duct Smoke Detectors
Heat Detectors
Gas Detectors
Waterflow Switches
Tamper Switches
Copyright C 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)
9. NOTIFICATION APPLIANCES
Type Quantity Description
Audible
Visible 2 Strobes
Combination Audible and Visible 2 Horn/Strobes
10. SYSTEM CONTROL FUNCTIONS
Type Quantity
Hold-Open Door Releasing Devices
HVAC Shutdown
Fire/Smoke Dampers
Door Unlocking
Elevator Recall
Elevator Shunt Trip
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 cified herein has been installed according to all NFPA standards cited herein.
Signed: Cam' Printed name: i— et r Date: 9/3*
Organization: Capitol Electric Title: cL2LTY1 C f c&w Phone: S-07-2-co - 3o 9 3-
12.2 System Operational Test
This system aa- ified herein has tested�according to all NFPA standards cited herein.
Signed: tsiA�a��` /,l E�iEu" Printed name: David Bartlett Date: 9/3/15
Organization: SimplexGrinnell Title: System Tech 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 m 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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