Report n
20fic, a
SYSTEM RECORD OF COMPLETIOfps
I his form is to he completed by the system installation contractor at thi'time of system acceptance and apj'rmal.
It shall be pe rvnitteorl trr modilit'this artn as needed to provide a more complete ant//or clear record
instil A'a•1 ur ralf unused limas.
Attach additional sheets. data, or calculations as net ertari to provide a complete record
Form Completion I tate: ' ( CI ._�....1:$ Supplemental}'age'Attached:
1. PROPERTY INFORMATION
Name of property: lL sus t „ (zt/2 Gni y Ey t- k -E,,A c i I-I r
Address: 32.4 E 5-(Nera.cltic w - / -rGI or_ 72 z x
Description of property: £ 1-?,,91A-Wc c l
Name of property representative: 1,37t/t‘ /J0 C iG a-et L,
Address: A Of' It`l/-�i✓G1Z;��
2
f'Imne a C 3 J - 7f
Fax: E-mail:
2. INSTALLATION,SERVICE, TESTING, AND MONITORING INFORMATION
Installation contractor: AMERICAN SECURITY, INC.
Address:
5411 SE MCLOUGHLIN BLVD.. PORTLAND. OR 97202
Phone. 503-231-0303 Fax: 503-230-1044 f-maul: (e�SARAASALARM S.COM
sService or: aniznnon:
AMERICAN SECURITY, INC.
Address: 5411 SE MCLOUGHLIN BLVD.. PORTLAND. OR 97202
Phone: 503-2310303
i hone: Fax: 503-230-1044 i>_maiI- SARA@ASALARMS.COM
Testitis organization:
RICAN SECURITY, INC.
Address:
5411 SE MCLOUGHLIN BLVD.. PORTLAND. OR 97202
Phone: 503-231-0303 Fa, 503-230-1044 l- mail. SARA@ASALARMS.COM
Effective date for test and inspection contract:
Monitoring organization:
CRITICOM MONITORING SERVICE
Address: 11130 HOLDER ST., CYPRESS, CA 90630
Phone: 1-800-883-2368 E-mail: WWW.CMSN.COM
z
Account number: /3 Z Plume line I: 5 3 Sfg.3 570 Phone
l iinL : {(e
,39-677
Means of transmission: '�C_Gife �J✓Z-._27 �j ��l>.//yr e (ay'
Entity to which alarms are retransmitted: FIRE DEPT. Phone: BY TELEPHONE/LANDLINE
3. DOCUMENTATION
Oh-site location of the required record documents and circ-specitic software: AT THE FACP
.
4. DESCRIPTION OF SYSTEM OR SERVICE
This is at 0e` _....._ ltloch /atontjfrv.F'Sat�`- Permit number: rep ...-Z61 ..... ..`., e-/S'
NF'1 72 edition: 2013 �?� a6Ze
4.1 Control Unit
Manufacturer: / r t c)
— ........ / Model number: } 4
4.2 Software and Firmware //
Firmware revision number: 20
4.3 Alarm Verification X This system docs not incorporate alarm verifiention.
Number of devices subject to alarm vet ificntir?n: 0
A Situ S Cii fit fin set Il in seconds
Copyright 020'12 Naticnei Fire Prix/et,t-,Aesac,atioe, 'this form mei'he cr rad for irrq v,tr,-tse other qisr110 'es,?a it prat eat to C'P:_1-.are ce , 'er,t1 sa...e r7 s'r/ t,--
6. 1ST"RECORDAC0P����B�N ��b�e�
SYSTEM��V �
5L1Cvnon|Unit
�|.1pr���yPower
12
Input`�mgumf"nm»l panel: ___
overcnrr�
en
�,
nmteo
Mv__
xr-
�._
-__
ELECTRICAL—
-_-.
-�-_w-�_
B,-|__-R__
G__4KE_� R
Branch circuit illmcomou/nameans location: ELECTRICAL PANEL
5.1zmett* oo,ymwer
Location.
i|remote
BATTERY
��or�m mx�v�
front��p|nm/: /)
Calculated capacity vfsecondary power wdrive the sysumt
instandby mode(b"vr0'
5.2 Control Unit 24 HOURS
This system does not have ptNe,,xunde,panels
ro",,extender panels 00e /b
� C�Cu|TSAND PATH S
wPyauUuwoeyType
Signe
Device Power
Initiating Device
Notification AnnUa/um
ual Media
0mo(�'�&):
Pathway Separate Pathway
7. REMOTE ANmDNC6ATORDS
TypeF ~t-
-_--__-__--
__-
.5;44/7I
~ -''
-_ / ‘,4,
CES INITIATINGDEVl
Type
ddr
mam�PvV�nhrna Quantity Aeouu
Conventional
S n kc Detectors
Duct Smoke Detectors
Heat Detectors
Gas DetectoN
Wtiterflow Switches
runner Switehe-
b}vn,e7Control pan
mum)yom'd �-�amps:
Number: 20
m|o »mode oxinrton.:
Class
ALARM
�_---_-��_-_-__--_----_
S-urvivability Level
5MINUTESALARM
0
A(mnnorSuper
_ -_ G_no_swToo / __--
_
g
- -
PHOTOELECTRIC SUPERVISORY sldrii Copyright e 2012 Nattonal F.tewote,,on Asqocra'n, tt fo=ttilf fo, �r t:.tt����=
•
SYSTEM RECORD OF COMPLETION (continued)
9. NOTIFICATION APPLIANCES
Type Quantity 1 Description
Auciihle. f
Visible —_
Combination Audible azulVisible /3 /r'I S .fl.
10. SYSTEM CONTROL FUNCTIONS
Type
Quantity
}Mid—Open Door Releasing l7cc lees /He-,3 y7
1-IVAC Shutdown
Fire/Smoke Dampers
Door Unlocking
Elevator Recall
...........
Elevator Shunt Trip
11. INTERCONNECTED SYSTEMS
a This system does not have interconnected systems.
0 Interconnected systems are listed on supplementer tr sheet
12. CERTIFICATION AND APPROVALS
12.1 System Installation Contractor
This system as lee Lied/herein has been installed according to all NFP.A.standards cited herein
Signed: // 4� l'nnted name.: e.'4 /��,.7 s' Date. _j /j
t)rganizatinn:AMERICAN SECNURITY, lids: TECH pl}trt,,.. 503-231-0303
12.2 System Operational Test
This system as s i'citi!herein :.:tested according to all hi Pet standards cited herein._
Signed: _, _ Printed j V Printedname: /'f `G.2; 7'� Date;
A1 `- l
_
AMERICAN SECURITY' INC TECH 503-231-0303
Organization I file:
Plittie:
12.3 Acceptance Test
Date ansI time or acceptance test.
Installing contractor representaticc- - ,f/L-?
\
Testing contractor representative: �
Property representative:
,„,—,
AHJ representative: '`•-•)EC-(- lit ILC_- C '
Ceeyrrght,';207 2 tattn+tai rirs t'rotecton Assavat.on This tar r may tip rrµ,rfi fqr it .tura rsi ir,a,rr+r tai,,r,:....ata S inu net tie.r;:,,:1 hr cc r r.:rs'Tae or ri tn'Cr,