Report (2) • FPS Zo
070
FIRE ALARM SYSTEM RECORD OF COMPLETION
To be completed by the.system installation contractor at the time of system acceptance and approval.
1. Protected Property Information
Name of property: f}C(il C ••
Address: ,..._ 12,9 el_._ slo (o$" ,..._ 14ttr..1A�
Description of property QA.c Tftkis T QF Ft Gts .' lv I L,.D IN/c
Occupancy type: _f3
f3
Name ofro
p perty representative: l�N �IV I TA r k.A
Address: _.._._ ( 53 50 StN 5 E Q V X71 A pk f it~/A-y ofiffoo
Phone: (7 5-4z y 6300 Fax: E-mail:
Authority having jurisdiction over this property: ( I'r' O 1c o
Phone:503 x`719-L(j3 I Fax: E-mail:
2. Are Alarm System Installation,Service,and Testing Information
Installation contractor for this equipment: P 1 NT__..1 ION 1T0
Address: _ S.Q(p3 L WE t4.) DLVI) $(HITT 10o
Phone: 7-.01_00__ Fax: 50 '''‘,21-01c0 E-mail:
Service organization for this equipment 57A/.4t . &jIU V MCeit-Fr Se.CU Ri T' Se LuT10A'S
Address: (OtictS. SW re evn to ? s.ttwikY t�1�o �rie,*.o,._ pIZ_ 172z4
Z4
Phone: 503 - roe-•3,330e Fax:
• E-mail:
Location of as-built drawings: Fier Location of Historical Test Reports: g7AH t.f 7
Location of system operation and maintenance manuals: STAN L Y
A contract for test and inspection in accordance with NFPA standards is in effect as of
Contracted testing company: STA N L-t'4 C 5S
Address: 15915 $W peavolh Pik ttk wPY 1/DO , _..._....
vitvi
Phone: �!` ax9-3 300 _..
---- Fax: E-mail:
Contract expires: ..__ Contract number: — - — — Frequency of routine inspections:
3. Type of Fire Alarm System or Service
NFPA 72m Chapter Reference of System Type: Ft/I C.D/A,4 Rite _ALA l+K rYS?'E±k 1... t1i4 CEW AAI.
Name of organization receiving alami signals with phone numbers(f applicable): .Mi I TA/Wf
Alarm: SCAN Lest C S
Phone: _._.�77 opt
Supervisory: $TAht LEY CSS Phone: __--
Trouble: STANLEY CSS Phone: sI
Entity to which alarms are retransmitted: Gnpp 9 s /!s-
�J�n_C.__ __-. .��r_C�A Phone: d �
Method of retransmission of alarms to that organization or location: DI ,TA L
NFPA 72,Fig.4.5.2.1 (p. 1 of 5)
Copyright t 2009 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.
If Chapter 8,note the means of transmission from the protected premises to the central station:
, 'Digital alarm communicator 0 McCulloh 0 Multiplex 0 2-way radio 0 1-way radio 0 N/A
If Chapter 9,note the type of connection: 0 Local energy 0 Shunt ❑N/A
3.1 System Software
Operating system(executive)software revision level:
Site-specific software revision date: Revision completed by:
4. Signaling Line Circuits
Characteristics ofsignalingline circuits connected to this system(see NFPA 72a,Table 6.6.1):
Quantity: 7 Style: Class:
5. Alarm-Initiating Devices and Circuits
Characteristics of initiating device circuits connected to this system(see NFPA 72®.Table 6.5):
Quantity: .__-... Style: Class:
5.1 Manual Initiating Devices
5.1.1 Manual Pull Stations Number of manual pull stations: t
Type of devices: Pg Addressable ❑Conventional ❑Coded 0 Transmitter ❑N/A --5.2 Automatic Initiating Devices
5.2.1 Area Smoke Detectors Number of smoke detectors: Z'
Type of coverage: 0 Complete area 0 Partial area kr Nonrequired partial area 0 N/A
Type of devices: gAddressable 0 Conventional 0 Coded 0 Transmitter ❑N/A
Type of smoke detector sensing technology: 0 Ionization rPhotoelectric
5.2.2 Duct Smoke Detectors Number of duct smoke detectors: �/Z
Type of coverage:
• Type of devices: Ca Addressable 0 Conventional 0 Coded 0 Transmitter 0 WA
•
Type of smoke detector sensing technology: 0 Ionization 13 Photoelectric
5.2.3 Heat Detectors Number of heat detectors: 0 •
Type of coverage: ❑Complete area 0 Partial area ❑Nonrequired partial area ❑N/A
Type of devices: 0 Addressable ❑Conventional 0 Coded 0 Transmitter ❑N/A
5.2.4 Sprinkler Waterflow Detectors Number of waterflow detectors: H.. Ara.._ . 0405 ._t_PFt__ A
Type of devices: Qif Addressable 0 Conventional ❑Coded ❑Transmitter ❑N/A
5.2.5 Alarm Verification• Number of devices subject to alarm verification: 0
Alarm verification on this system is:❑Enabled 121Disabled ❑Set for seconds
6. Supervisory Signal-Initiating Devices and Circuits Y lei Self VALY ES _ / rex'FLA
6.1 Sprinkler System Number of valve supervisory switches: 3 gemore lot L V E S ON /n''VO X
Type of devices: 'Addressable 0 Conventional ❑Coded 0 Transmitter ❑N/A
NFPA 72,Fig.4.5.2.1 (p.2 of 5)
Copyright 0 2009 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.
6.2 Fire Pump /u
Type of fire pump: 0 Electric 0 Diesel
Type of fire pump supervisory devices: 0 Addressable 0 Conventional 0 Coded 0 Transmitter ❑N/A
Fire Pump Functions Supervised
0 Fire pump power 0 Fire pump running 0 Fire pump phase reversal 0 Selector switch not in auto
❑Engine or control panel trouble 0 Low fuel
Other:
6.3 Engine-Driven Generator ,V4
Type of generator supervisory devices: 0 Addressable 0 Conventional 0 Coded 0 Transmitter ❑N/A
❑Engine or control panel trouble 0 Generator running 0 Selector switch not in auto 0 Low fuel
Other:
7. Annunciators
7.1 Annunciator 1 irLocal 0 Remote
Type:0 Addressable 0 Directory 0 Graphic 0 N/A Location: 'ACI' $V
7.2 Annunciator 2Local 0 Remote
Type:D Addressable 0 Directory 0 Graphic 0 N/A Location: esT euT8-Y
7.3 Annunciator 3 0 Local 0 Remote
Type:D Addressable ❑Directory ❑Graphic ❑N/A Location:
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8. Alarm Notification Devices and Circuits
8.1 Emergency Voice Alarm Service AI161
Number of single voice alarm channels: _-T- Number of multiple voice alarm channels:
Number of speakers: Number of speaker zones:
8.2 Telephone Jacks NA "Number of telephone jacks installed: Number of telephone handsets stored on site:
Type of telephone system installed: 0 Electrically powered 0 Sound powered 0 N/A
8.3 Nonvoice Audible System
Characteristics of notification device circuits connected to this system(see NFPA 72®,Table 6.5):
Quantity: 2.0 !thG CUt VlTSstyle: _ _— -- Class:
8.4 Types and Quantities of Nonvoice Notification Appliances Installed 113
Bells: SLAM/m"4 With visual device: Horns: *-474--42 With visual device: ye-s:
Chimes: With visual device: Bells: With visual device:
Visual devices without audible devices: eq.- 2.7 Other(describe):
NFPA 72,Fig.4.5.2.1 (p.3 of 5)
Copyright®2009 National Fire Protection Association.This form may be copied for individual use other then for resale.It may not be copied for commercial sale or distribution.
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9. Emergency Control Functions Activated
• 'Hold-open door releasing devices rfrSmoke management or smoke control
iRt Door unlocking gi Elevator recall ❑Other
10.System Power Supply
10.1 Primary Power
Nominal voltage: __ I ZO VAC Amps:
Overcun-ent protection: Type: RticA
._._. ..__..__....._Kt'R ___.________ Amps: ______.__
Location(of primary supply panelboard): iT pp/L Et ;L k 4` o K
Disconnecting means location: If T FLO OA Et.e t,rNit(..M,
10.2 Secondary Power
Location: Type: Nominal voltage: — Current rating:
Number of standby batteries: (' f() y/Y.AC P(&Amp hour rating: _15A+3 gyp.
Location of emergency generator:
Location of fuel storage:
Calculated capacity of secondary power to drive the system
In standby mode: zy x_....__._ -._--__-.. In alarm mode: /NI N
11.Record of System Installation
Fill out after all installation is complete and wiring has been checked for opens,shorts,ground faults,and improper
branching,but before conducting operational acceptance tests.
The system has been installed in accordance with the following NFPA standards:(Note any or all that apply.)
o"NFPA 72® NFPA 70°Article 760
Manufacturer's published instructions 0 Other(please specify):
System deviations from referenced NFPA standards:
Signed: !',(�(,f(.rj,JW
�y �r_ ..._.__._.._ Printed name. ray Date
Organization: O / 'Nom Title: 3-.319...__74 1
P _..._Z�'r,N. __._._._._._.—___._...- --- Phone: ..
12.Record of System Operation
All operational features and functions of this system were tested by or in the presence of the signer shown below,on the date
shown below,and were found to be operating properly in accordance with the requirements of:
❑NFPA 72° 0 NFPA 70®,Article 760
❑Manufacturer's published instructions - 0 Other(please specify):
❑Documentation in accordance with Inspection and Testing Form(Figure 10.6.2.3 of NFPA 72°)is attached
Signed: _`.__....— Printed name: Date:
Organization: • Title: Phone:
NFPA 72,Fig.4.5.2.1 (p.4 tot 5)
Copyright 5 2009 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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13.Certifications and Approvals
• 13.1 System Installation Contractor
This system as specified herein has been installed and tested according to all NFPA standards cited herein.
Signed: _—__�---...__.___ Printed name: Date:
Organization: _____ Title:Title: Phone:
13.2 System Service Contractor
This system as specified herein has been installed and tested according to all NFPA standards cited herein.
Signed: Date:
Printed name:
Organization: Title: Phone:
13.3 Central Station
This system as specified herein will be monitored according to all NFPA standards cited herein.
Signed: Printed name: Date:
Organization: Title: Phone:
13.4 Property Representative •
I accept this system as having been'installed and tested to its specifications and all NFPA standards cited herein.
Signed: Printed name:' Date:
Organization: Title: Phone:
13.5 Authority Raving Jurisdiction
I have witnessed a satisfacto acceptance test of this system and find it to be installed and operating properly in accordance
with its approve p1- s and ecifications,its approved sequence of operraftiioo s,and with all NFPA standards cited here'
Signed: / - Printed name: v'!#T 4-rev-s, Date: ,S /S`
Organization: , Title: J�[�K�yL I Phone:
•
NFPi4 72,Fig.4.5.2.1 (p.5 of 5)
Copyright C2009 National Fire Protection Association.The form may be copied for individual use other than for resale.ft may not be copied for commercial sale or distribution.