Report p s S 20 I __ U 05F�
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: 62 — 7 -/ Supplemental Pages Attached:
1. PROPERTY INFORMATION
Name of property: 13 eV E (-ANJ
Address: C:1 SW EVES & (l G,4ti)R"►4 nL 97 21
3
Description of property: t 0/4 I E L L.rt tic L, ?:.).S I ni CS S
Name of property representative:
Address:
Phone: Fax: E-mail:
2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION
Installation contractor: P01 i j I*0,4
Address: 5 S(a 3 L '&r.) l3LVD.4.1O- l Lk" OS( &) t O4- `17o3S
Phone: Fax: E-mail:
Service organization:
Address:
Phone: Fax: E-mail:
Testing organization:
Address:
Phone: Fax: E-mail:
Effective date for test and inspection contract:
Monitoring organization: n'4. C STA-
Address:
Phone: 5t) 3 io ( Co-)t. I Fax: E-mail:
Account number: 91-0D - q3u, Phone line 1: 46-03(a LJ ' ? 3 Phone line 2: 51) ‘4,-.2-.") 3 �(
Means of transmission: TS (..-i")
Entity to which alarms are retransmitted: —I) 6-442-0 �� • Phone: 9
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 [j-Modfification to existing system Permit number: FL oDcs - Ds6
NFPA 72 edition: a()(/3
4.1 Control Unit � '
Manufacturer: U&-r-S( yy�-G.A 6441--
Model number:
4.2 Software and Firmware
Firmware revision number:
4.3 Alarm Verification ❑This system does not incorporate alarm verification.
Number of devices subject to alarm verification: Alarm verification set for seconds
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)
5. SYSTEM POWER
5.1 Control Unit
5.1.1 Primary Power A
Input voltage of control panel: l V. A Control panel amps:
Overcurrent protection: Type: ptteA-tcl/ Amps: Q!Q>
Branch circuit disconnecting means location: `I' `'et, p1(Sf- Number: 't)1
5.1.2 Secondary Power
Type of secondary power:
Location,if remote from the plant: Le
Calculated capacity of secondary power to drive the system: rr
In standby mode(hours): � In alarm mode(minutes): J,
5.2 Control Unit
❑ This system does not have power extender panels
I P wer extender panels are listed on supplementary sheet A
6. CIRCUITS AND PATHWAYS
Pathway Type I Dual Media Pathway Separate Pathway Class I Survivability Level
Signaling Line
Device Power
Initiating Device
Notification Appliance l a-J
Other(specify):
7. REMOTE ANNUNCIATORS
Type Location
8. INITIATING DEVICES
Addressable or
Type Quantity Conventional Alarm or Supervisory Sensing Technology
Manual Pull Stations 1
Smoke Detectors 7 0 A6 LC octt,i,‘ 194-toTb t,.t LIUC
-
Duct Smoke Detectors Q
Heat Detectors 0
Gas Detectors 0 _
Waterflow Switches
Tamper Switches
Copyright®2012 National Fire Protection Association.This form may be copied for individual use other than for resale.a 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 / q-%6A)
Combination Audible and Visible C3--6,1111-
10. SYSTEM CONTROL FUNCTIONS
Type Quantity
Hold-Open Door Releasing Devices 3
HVAC Shutdown (J
Fire/Smoke Dampers
Door Unlocking d
Elevator Recall
8
Elevator Shunt Trip
11. INTERCONNECTED SYSTEMS
LEI his system does not have interconnected systems.
❑ Interconnected systems are listed on supplementary sheet
12. CERTIFICATION AND APPROVALS
12.1 System Installation Contractor
This system ecified herein has been installed according to all NFPA standards cji, herein.
Signed: •( ,� � Printed name: L 0 `(iu Date: 6
Organization: (t.!r I U), TI ail. Title: J (8 'L f 4� ) Phone: 9)3 102-)01 °
12.2 System Operational Test
This system specified ein has tested according to all NFPA standards cited herein.
Signed: Printed name: -PPO Mei€J n L, Date:
Organization: aQOt JT ot� Title ��'f L Ps- Phone: 'O3 & ) 0/ at)
12.3 Acceptance Test
Date and time of acceptance test:
Installing contractor representative:
Testing contractor representative:
Property representative:
AHJ representative:
Copyright®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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