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Report vpsao l 5 - qty Sw_k) Certificate of Completion Name of Protected Property: Washington Square Mall-Lolli and Pops Suite G12 Address: 9585 SW Washington Square Road _ Tigard, OR 97223 s Rep. of Protected Prop. (name/phone): Roger Ott 503.352.8879 Authority Having Jurisdiction: City of Tigard Address: Phone Number: 1. Type(s) of System or Service: X NFPA 72, Chapter 3-Local If alarm is transmitted to location(s)off premise, list where received: ISA Monitoring 866.341.2943 Account 6959950 NFPA 72, Chapter 3-Emergency Voice/Alarm Service Quantity of voice/alarm channels: Single: Multiple: Quantity of speakers installed: Quantity of speaker zones: Quantity of telephones or telephone jacks included in system: NFPA 72, Chapter 4-Auxiliary Indicate type of connection: Local energy, Shunt, Parallel telephone Location and telephone number for receipt of signals: NFPA 72, Chapter 4-Remote Station Alarm: Supervisory: NFPA 72, Chapter 4-Proprietary If alarms are retransmitted to public fire service communications center or others, indicate location and telephone number of the organization receiving alarm: Indicate how alarm is retransmitted: Updated: 10/28/2015 Page 1 T:\Fire\Misc\Commissioning Fomis\master cert comp.doc NFPA 72, Chapter 4-Central Station The Prime Contractor: Central Station Location: Means of transmission of signals from the protected premise to the central station: McCulloh Multiplex One-Way Radio Digital Alarm Communicator Two-Way Radio Others Means of transmission of alarms to the public fire service communications center: 1. 2. System Location: Organization Name/Phone Representative Name/Phone Installer Advanced Wiring Services Mark Beatty 503.310.3655 Supplier Siemens Industry, Inc. E.J. Fannuchi 971.563.8869 Service Organization Siemens Industry, Inc. Service Department 503.207.1900 Location of Record (As-Built) Drawings: Location of Owners Manuals: Location of Test Reports: A contract, dated for test and inspection in accordance with NFPA standard(s) No.(s) dated is in effect. 2. Certification of System Installation (Fill out after installation is complete and wiring checked for opens, shorts, ground faults, and improper branching, but prior to conducting operational acceptance tests.) This system has been installed in accordance with the NFPA standards as listed below,was inspected by Mark Beatty on October 29,2015 , includes the devices listed below and has been in service since October 29, 2015 X NFPA 72, Chapters X 1 X 3 X 4 X 5 X 6 X 7(check all that apply) X NFPA 70, National Electrical Code, Article 760 X Manufacturer's Instructions Other(spec' Signed: � . Date: !0 Organization: Advanced Wiring Services Updated: 10/28/2015 Page 2 T:\Fire\Misc\Commissioning Forms\master cert comp.doc 3. Certification of System Operation All operational features and functions of this system were tested by Jim Bramlage on October 29, 2015 and found to be operating properly in accordance with the requirements of: X NFPA 72, Chapters X1 X3 X4 X5 X 6 X7 (check all that apply) X NFPA 70, National Electrical Code, Article 760 X Manufacturer's Instructions X Other(specify): Signed: @1L1fLjpw%.Q .. Date: I Oft 3/1C Organization: Siemens Indus , Inc. 4. Alarm Initiating Devices and Circuits (Use blanks to indicate quantity of devices.) MANUAL a) 0 Manual Stations Noncoded,Activating Transmitters Coded b) 0 Combination Manual Fire Alarm and Guard's Tour Coded Stations AUTOMATIC Coverage: Complete Partial a) 0 Smoke Detectors: Ion Photo b) 0 Duct Detectors: Ion Photo c) 0 Heat Detectors: FT RR FT/RR RC d) 0 Sprinkler Water Flow Switches: Noncoded,Activating Transmitters Coded e) 0 Other(list): 5. Supervisory Signal Initiating Devices and Circuits (Use blanks to indicate quantity of devices.) GUARD'S TOUR a) 0 Coded Stations b) 0 Noncoded Stations Activating Transmitters c) 0 Compulsory Guard Tour System Comprised of Transmitter Stations and Intermediate Stations Note: Combination devices recorded under 4(b)and 5(a). SPRINKLER SYSTEM a) 0 Coded Valve Supervisory Signaling Attachments 0 Valve Supervisory Switches Activating Transmitters b) 0 Building Temperature Points c) 0 Site Water Temperature Points d) 0 Site Water Supply Level Points Updated: 10/28/2015 Page 3 T:\Fire\Misc\Commissioning Forms\master cert comp.doc Electric Fire Pump: e) 0 Fire Pump Power f) 0 Fire Pump Running g) 0 Phase Reversal Engine-Driven Fire Pump: h) 0 Selector in Auto Position i) 0 Engine or Control Panel Trouble j) 0 Fire Pump Running Engine-Driven Generator: k) 0 Selector in Auto Position I) 0 Control Panel Trouble m) 0 Transfer Switches n) 0 Engine Running Other Supervisory Function(s)(specify): N/A 6. Alarm Notification Appliances and Circuits Quantity of indicating appliance circuits connected to the system: 2 modified Types and quantities of alarm indicating appliances installed: a) 0 Bells Inch 2 Speakers b) 0 Horns c) 0 Chimes d) 0 Other: e) 4 Visual Signals Type: Speaker/Strobe and Strobe 2 with audible 2 w/o audible f) 0 Local Annunciator 7. Signaling Line Circuits: Quantity and Style (See NFPA 72,Table 3-6.1)of signaling line circuits connected to system: Quantity: 0 Style: 8. System Power Supplies a) Primary(Main): Nominal Voltage: 120VAC Current Rating: 20a Overcurrent Protection: Type: Breaker Current Rating: 2a Location: Fire Alarm Control Panel power supply b) Secondary(Standby): X Storage Battery: Amp-Hour Rating 55ah (main), 8ah (booster) Calculated capacity to drive system, in hours: X 24 _ 60 0 Engine-driven generator dedicated to fire alarm system: Location of fuel storage: Updated: 10/28/2015 Page 4 T:\Fire\Misc\Commissioning Forms\master cert comp.doc c) Emergency or Standby System used as backup to Primary Power Supply, instead of using a Secondary Power Supply: 0 Emergency System described in NFPA 70, Article 700 0 Legally Required Standby System described in NFPA 70, Article 701 0 Optional Standby System described in NFPA 70, Article 702,which also meets the performance requirements of Article 700 or 701 9. System Software a) X Operating System Software Revision Level(s): CSGM 17.07 b) NA Application Software Revision Level(s): c) NA Revision Completed by: no program changes Siemens Industries, Inc. (name) (firm) 10. Comments: art_Bitevy0 FIRE spec ioer...1s 4 I0 2.9/15 (signed)for Central tion or Alarm Service Company (title) (date) Frequency of routine tests and inspections, if other than in accordance with the referenced NFPA standard(s): System deviations from the referenced NFPA standard(s)are: (signed)for Central Station or Alarm Service Company (title) (date) Upon completion of the system(s)satisfactory test(s)witnessed (if required by the authority having jurisdiction: (signed)representative of the authority having jurisdiction (title) (date) Updated: 10/28/2015 Page 5 T:\Fire\Misc\Commissioning Forms\master cert comp.doc