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Report (5) ri.) &OK-Oo 1S.$ ti 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: 10-21-15 Supplemental Pages Attached: NO 1. PROPERTY INFORMATION Name of property: Lincoln 1 Mastercare 380 Address: 10300 SW Greenburg Tigard,OR 97223 Description of property: Name of property representative: Shorenstein Reality Services Address: 10220 SW Greenburg Tigard OR 97223 Phone: Fax: E-mail: 2. INSTALLATION, SERVICE, TESTING, AND MONITORING INFORMATION . Installation contractor: Capitol Electric Address: 11401 NE Marx Portland OR 97220 Phone: Fax: E-mail: Service organization: Address: Phone: Fax: E-mail: Testing organization: SimplexGrinnell Address: 6305 SW Rosewood Lake Oswego OR 97035 Phone: 503-683-9001 Fax: 503-675-6521 E-mail: Effective date for test and inspection contract: Monitoring organization: See Owner Rep Unknown 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: FACP 4. DESCRIPTION OF SYSTEM OR SERVICE This is a: ❑New system Si Modification to existing system Permit number: NFPA 72 edition: 2013 4.1 Control Unit Manufacturer: Simplex Model number: 4100U 4.2 Software and Firmware Firmware revision number: 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©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 (p. 1 of 3) SYSTEM RECORD OF COMPLETION (continued) 5. SYSTEM POWER 5.1 Control Unit 5.1.1 Primary Power Input voltage of control panel: 120vac(4009A NAC PANEL) Control panel amps: 8 Overcurrent protection: Type: Breaker Amps: 20 Branch circuit disconnecting means location: Existing,unchanged Number: Existing, unchanged 5.1.2 Secondary Power Type of secondary power: Batteries Location,if remote from the plant: Calculated capacity of secondary power to drive the system: In standby mode(hours): 24 In alarm mode(minutes): 5 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 0 0 0 0 Device Power 0 0 0 0 Initiating Device 0 0 0 0 Notification Appliance 0 1 B 1 Other(specify): Broke 1 Existing Circuit into 2 Circuits 7. REMOTE ANNUNCIATORS Type Location Existing,unchanged 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©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. (p. 2 of 3) SYSTEM RECORD OF COMPLETION (continued) 9. NOTIFICATION APPLIANCES Type Quantity Description Audible Visible 3 Existing, Relocated Combination Audible and Visible 2 Existing, Relocated 10. SYSTEM CONTROL FUNCTIONS Type Quantity Hold-Open Door Releasing Devices Existing,unchanged HVAC Shutdown Existing, unchanged Fire/Smoke Dampers Existing,unchanged Door Unlocking Existing,unchanged Elevator Recall Existing,unchanged Elevator Shunt Trip Existing,unchanged Existing,unchanged Existing,unchanged 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 specified herein has been installed according to all NFPA standards cited herein. Signed: � Printed name: wat-j‘-c fr6 Date: /Oi/t r//S Organization: cG,.n,A 'C Title: jnc(c.< L-, Phone: 5-03 ^ '9Y:'Y 12.2 System Operational Test This system as specified herein has tested according to all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: 12.3 Acceptance Test Date and time of acceptance test: Installing contractor representative: Testing contractor representative: Property representative: AHJ representative: 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. (p. 3 of 3)