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Report Y + -0 ✓ is— Vvv 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: 4/16/15 Supplemental Pages Attached: 0 1. PROPERTY INFORMATION Name of property: Four Lincoln Center Address: 10260 SW Greenburg Rd., Portland, OR 97223 Description of property: Name of property representative: Shorenstein Realty Services Address: 10220 SW Greenburg Rd., Portland, OR 97223 Phone: Fax: E-mail: 2. INSTALLATION, SERVICE, TESTING, AND MONITORING INFORMATION Installation contractor: Capital Electric Address: 11401 NE Marx St., Portland, OR 97220 Phone: Fax: E-mail: Service organization: SimplexGrinnell Address: 6305 SW Rosewood St., Suite A, Lake Oswego, OR 97035 Phone: 503-683-9000 Fax: 503-675-6521 E-mail: Testing organization: SimplexGrinnell Address: 6305 SW Rosewood St., Suite A, Lake Oswego, OR 97035 Phone: 503-683-9000 Fax: 503-675-6521 E-mail: Effective date for test and inspection contract: 6/30/2104-7/1/2016 Monitoring organization: Address: Phone: Fax: E-mail: Account number: Phone line 1: Phone line 2: Means of transmission: Entity to which alarms are retransmitted: Phone: 3. DOCUMENTATION On-site location of the required record documents and site-specific software: on-site 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: SimplexGrinnell Model number: 41000 4.2 Software and Firmware Firmware revision number: - 4.3 Alarm Verification El 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. (p. 1 of 3) 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: 6A Overcurrent protection: Type: Breaker Amps: 20A Branch circuit disconnecting means location: Number: 5.1.2 Secondary Power Type of secondary power: (2) 12vDC/33Ah Lead-Acid Batteries Location,if remote from the plant: FACP Calculated capacity of secondary power to drive the system: In standby mode(hours): 24 hours In alarm mode(minutes): 15 minutes 5.2 Control Unit ❑ This system does not have power extender panels ® Power extender panels are 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 Other(specify): 7. REMOTE ANNUNCIATORS Type Location LCD Main Lobby LCD FACP 8. INITIATING DEVICES Addressable or Type Quantity Conventional Alarm or Supervisory Sensing Technology Manual Pull Stations - Smoke Detectors - Duct Smoke Detectors - Heat 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. (p.2 of 3) SYSTEM RECORD OF COMPLETION (continued) 9. NOTIFICATION APPLIANCES Type Quantity Description Audible - Visible 4 Strobe only 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 NFPA standards cited herein. Date: 41/4/1/S-- Signed: S'7 Printed name: d 'iGt f f?= f Organization: 4:./4A/ (C,. Title: I"c � ���; . ( G .A/ti L--• Phone: SG t Z S C/y pr 12.2 System Operational Test This system as specified herein has tested according to all NFPA standards cited herein. Signed: " `-- -- Printed name: Brian Giannettino Date: 4/16/15 Organization: SimplexGrinnell Title: A&D Supervisor Phone: 503-683-9000 12.3 Acceptance Test Date and time of acceptance test: Installing contractor representative: Testing contractor representative: Property representative: AHJ 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. (p.3 of 3)