Report (4452coa , ot) 07?
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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: 6-2-16 Supplemental Pages Attached: 0
1. PROPERTY INFORMATION
Name of property: Lincoln 2 AJ Gallagher INS Suite 500
Address: 10220 SW Greenburg rd Tigard OR 97223
Description of property: Business Group
Name of property representative: Shorenstein Reality Services
Address: Same As Above
Phone: Fax: E-mail:
2. INSTALLATION, SERVICE,TESTING,AND MONITORING INFORMATION
Installation contractor: Capitol Electric
Address: 11401 NE Marx st Portland OR 97220
Phone: 971-506-3072 Fax: Dan Wilson E-mail:
Service organization: SimplexGrinnell
Address: 6305 SW Rosewood St Lake Oswego,OR.97035
Phone: 503-683-9000 Fax: 503-675-6521 E-mail:
Testing organization: SimplexGrinnell
Address: 6305 SW Rosewood St Lake Oswego,OR.97035
Phone: 503-683-9000 Fax: 503-675-6521 E-mail:
Effective date for test and inspection contract:
Monitoring organization: By Others,see Shorenstein or Lincoln Tower Security
Address:
Phone: Fax: E-mail:
Account number: Phone line 1: N/A Phone line 2: N/A
Means of transmission: RF
Entity to which alarms are retransmitted: Phone:
3. DOCUMENTATION
On-site location of the required record documents and site-specific software: FACP RM
4. DESCRIPTION OF SYSTEM OR SERVICE
This is a: 0 New system ®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:
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.
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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: Existing(NAC PNL) Control panel amps: 8
Overcurrent protection: Type: Breaker Amps: 20
Branch circuit disconnecting means location: Number:
5.1.2 Secondary Power
Type of secondary power: Fire Alarm Batteries Existing
Location,if remote from the plant:
Calculated capacity of secondary power to drive the system:
In standby mode(horns): 24 In.ala i mode.(minutes): 5
5.2 Control Unit
❑ This system does not have power extender panels
❑ Power extender panels are listed on supplementary sheet A
Pathway Type Dual Media Pathway Separate Pathway Class Survivability Level
Signaling Line
Device Power
Initiating Device
Notification Appliance 1 MODIFIED B 1
Other(specify):
7. REMOTE ANNUNCIATORS
Type Location
Existing
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.
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TTh?ETS REC'OFCb`01F-COMPLETION finyntrwate
9. NOTIFICATION APPLIANCES
Type Quantity Description
Audible 0
Visible 6 4906-9103
Combination Audible and Visible 4 4906-9129
10. SYSTEM CONTROL FUNCTIONS
Type Quantity
Hold-Open Door Releasing Devices 0
HVAC Shutdown 0
Fire/Smoke Dampers 0
Door Unlocking 0
Elevator Recall 0
Elevator Shunt Trip 0
11. INTERCONNECTED SYSTEMS
This system does not have interconnected systems.
12. CERTIFICATION AND APPROVALS
12.1 System Installation Contractor
This system specified re has been installed according to all NFPA standards cited herein.
Signed:g L Printed name: Jim Date: 5-2-16
Organi 1. : Capitol Electric Title: Phone: 971-506-2912
12.2 System Operational Test
This system as specified herein has tested according to all NFPA standards cited herein.
Signed: printed name: R Swatski
Date: 5-2-16
Organization: SimplexGrinnell Title: SR Tech Rep Phone: 503-683-9000
12.3 Acceptance Test
Date and time of acceptance test: 5-3-16,0600hrs
Installing contractor representative: Jim
Testing contractor repres rr: `E ,
Property representative:
AHJ representative:
Copyright 0 2012 National Fire Protection Association.This form maybe copied for individual use other
P than for resale.It may not be copied for commercial sale or distrbution.
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