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Report (82) 48)-0/7-�v/0-7 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: — l Supplemental Pages Attached: r 1. PROPERTY INFORMATION Name of property: • ` Q.,At`.Q, Address: .1 Q .•u • a rdt 7 Description of property: ♦ �� © ` 12,3 { • Name of property representative: Address: Phone: Fax: E-mail: 2. INSTALLATION,SERV!�, TESTING,AND MONITORING INFORMATION Installation contractor: I f(\t- f o c 4yr C-601 Address: Se v 3 L e.v ��_t,� / / f 1ld. l�O I0 e. 0 *7035Phone: S(3 Fax: SQ)(L) O/U) E-mail: >i 12SSOi" P 14044 r't"�h Service organization: 0 al Address: ( O L -Se,u- >CQ 1 Phone: 3 6 3 ice, vs Liu -z> . 9-1z3S`" Fax: E-mail: Testing organization: Address: Phone: Fax: E-mail: Effective date for test and inspecti L contract: Monitoring organization: r USW- oft Address: Phone: • �J cX(15- 5-2c) I Fax: 2 I E-mail: Account number: Phone line 1: Phone line 2: Means of transmission: Entity to which alarms are retransmitted: Phone: q 3. DOCUMENTATION On-site location of the required record documents and site-specific software: 4. DESCRIPTION OF SYSTEM OR SERVICE This is a: 0 New systemodification to existing system Permit number: FPS o� C NFPA 72 edition: /�� 4.1 Control Unit Manufacturer: ( �l.F ,r�,� Model number: )tl2 4.2 Software and Firmware Firmware revision number: A- 4.3 4.3 Alarm Verification 0 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: /6-L) v4 Control panel amps: Overcurrent protection: Type: 13a.k Qr Amps: Branch circuit disconnecting means location: Number: 5.1.2 Secondary Power Type of secondary power: 1Q.r (C S Location,if remote from the plant: "ng61 CP Calculated capacity of secondary power to drive the system: In standby mode(hours): 4 In alarm mode(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 Lipe Device Power Initiating Device Notification Appliance ( Other(specify): 7. REMOTE ANNUNCIATORS Type Location 8. INITIATING DEVICES Addressable or Type Quantity Conventional Alarm or Supervisory Sensing Technology Manual Pull Stations 0 Smoke Detectors C) Duct Smoke'Detectors U Heat Detectors 0 Gas Detectors Waterflow Switches 0 Tamper Switches 0 Copyright 0 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 f, t,414%-le",,t1CCombinatiorlAudible and Visible 10. SYSTEM CONTROL FUNCTIONS 7� Type Quantity Hold-Open Door Releasing Devices HVAC Shutdown Fire/Smoke Dampers C) Door Unlocking Elevator Recall- C) C) 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 ecif er in has been installed according to all PA stan s cited herein. Signed: J t/ Printed name: Date: 8 `/ 1 , Organization: O 1/1 �— V-110114-11,\(-- Title: IZ Phone: SO 3 6 2')J(O V 12.2 System Operational Test This systerr - •ff rein has tested according to all NFPA s dards ci erein. Signed: V • Printed name: Date: g—,ace`1 —) Organization: ((0-(f RoA 11)(' Title: t'` ., �-Lr ` Phone: 5°3 ("1:1 V I� 123 Acceptance Test 22 / Date and time of acceptance test: C6 J(� ! tD: Installing contractor representative: 1t + ' Testing contractor representative: Property representative: AHJ representative: Copyright 0 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) NOTIFICATION APPLIANCE POWER PANEL SUPPLEMENTARY RECORD OF COMPLETION This form is a supplement to the System Record of Completion. It includes a list of types and locations of notification appliance power extender panels. T lir fc m fs to be canvistsd by fzersystainlasteediam a KM-1 systems# �.. �+. _. , It shall be permitted to modify this form as needed to provide a more complete and/or ear record �� Insert N/A in all unused lines. Fonn Completion Date: — ' t. Number of Supplemental Pages ! oPP Attached: 1. PROPERTY INFORMATION Name of property: 1 J Q ACQ, p Address: 1061('Q..Q/) b (ti5 � ( /Gard (( 9 7 2-2-3 2. NOTIFICATION APPLIANCE POWER EXTENDER PANELS Make and Model Location Area Served Power Source ��^^�� v� I 00 wiwimmin See Main System Record of Completion for additional information,certifications,and approvals. 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 1)