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Report (25) rff20( - COOL('(.9 SYSTEM RECORD OF COMPLETION t0)--C/0 G iV Lrai h /y This form is to be completed by the system installation contractor at the lime 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 NzA in all unused lines. Attach additional sheets, data,or calculations as necessary to provide a complete record. Form Completion Date: 06-16-16 Supplemental Pages Attached: 1. PROPERTY INFORMATION Name of property: Lincoln Tower Restroom Upgrade Address: 10260 SW Greenburg Rd.Tigard,OR. 97223 Description of property: B-AHC Business Group(Ambulatory Health Care) Name of property representative: Shorenstien Realty Services Address: 10220 SW Greenburg Rd.Tigard,OR.97223 Phone: Fax: E-mail: 2. INSTALLATION, SERVICE,TESTING,AND MONITORING INFORMATION Installation contractor: Capitol Electric Address: 11401 Marx St.Portland,OR.97220 Phone: Fax: E-mail: Service organization: SimplexGrinnell Address: 6305 SW Rosewood St Lake Oswego,OR. 97035 Phone: 503-683-9000 Fax: E-mail: Testing organization: Cosco Fire Address: Phone: Fax: E-mail: Effective date for test and inspection contract: Monitoring organization: Advantage Protection Address: Phone: Fax: E-mail: Account number: 5224 Phone line I: Phone line 2: Means of transmission: SDACT Entity to which alarms are retransmitted: Phone: 3. DOCUMENTATION On-site location of the required record documents and site-specific software: Fire Alarm Panel 4. DESCRIPTION OF SYSTEM OR SERVICE This is a: ❑ 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: 12.05.05 4.3 Alarm Verification ®This system does not incorporate alarm verification. Number of devices subject to alarm verification: Alarm verification set thr 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. SYSTEM RECORD OF COMPLETION (continued) 5. SYSTEM POWER 5.1 Control Unit 5.1.1 Primary Power Input voltage of control panel: 120vac Control panel amps: 8 Overcurrent protection: Type: Breaker Amps: 20 Branch circuit disconnecting means location: 3EL Number: 1 5.1.2 Secondary Power Type of secondary power: Fire Alarm Power Supply 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 arc 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 4 B 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 Ileat Detectors Gas Detectors Waterflow Switches Tamper Switches 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. SYSTEM RECORD OF COMPLETION (continued) 9. NOTIFICATION APPLIANCES Type Quantity Description Audible Visible 8 Wall Mount Device Combination Audible and Visible 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 specified herein has been installed according to all NEPA standards cited herein. Signed: Printed name: Date: 06-16-16 Organization: Capitol Electric Title: Foreman Phone: 12.2 System Operational Test This system as specified herein has tested according to all NEPA standards cited herein. Signed: Printed name: Ralph MacRoberts Date: 06-16-16 Organization: SimplexGrinnell Title: Tech Rep Phone: 503-683-9000 12.3 Acceptance Test Date and time of acceptance test: Installing contractor representative: Testing contractor representative: Property representative: AH.I 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.