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Report (69) 0,520/) ._6101.4,2-- 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 modem 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: 10/25/2017 Supplemental Pages Attached: 1 1. PROPERTY INFORMATION Name of property: NORDSTROM Address: 9700 SW WASHINGTON SQUARE RD Description of property: Name of property representative: JASON MCKINNEY Address: 9700 SW WASHINGTON SQUARE RD Phone: 408.476.5429 Fax: E-mail: jason.mckinney@nordstrom.corn 2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION Installation contractor: WESTERN STATES FIRE PROTECTION Address: 17500 SW 65TH AVE LAKE OSWEGO,OR 97035 Phone: (503)657-5155 Fax: E-mail: Service organization: SAME AS ABOVE Address: Phone: Fax: E-mail: Testing organization: SAME AS ABOVE Address: Phone: Fax: E-mail: Effective date for test and inspection contract: Monitoring organization: PROTECTION ONE Address: 7312 SW DURHAM RD. BUILDING H PORTLAND,OR.97224 Phone: 503.867.8628 Fax: E-mail: www.protectionl.com Account number: Phone line 1: Phone line 2: Means of transmission: COPPER PHONE LINES Entity to which alarms are retransmitted: Phone: 3. DOCUMENTATION On-site location of the required record documents and site-specific software: AT FACP 4. DESCRIPTION OF SYSTEM OR SERVICE This is a: 0 New system ®Modification to existing system Permit number: ALRM- NFPA 72 edition: 2012 4.1 Control Unit Manufacturer: FCI Model number: FCI SCU 7200 4.2 Software and Firmware Firmware revision number: N/A 4.3 Alarm Verification ®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: 120AC VOLT/OPERATING 24DC VOLT Control panel amps: 5A Overcurrent protection: Type: CIRCUIT BREAKER Amps: 20 Branch circuit disconnecting means location: LOCATED IN ELEC.RM Number: 5.1.2 Secondary Power Type of secondary power: SLA BACKUP BATTERIES 12DC VOLT 8AMP HOUR Location,if remote from the plant: N/A Calculated capacity of secondary power to drive the system: In standby mode(hours): 24 In alarm mode(minutes): 10 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 B 1 Notification Appliance B 1 Other(specify): 7. REMOTE ANNUNCIATORS Type Location 8. INITIATING DEVICES Addressable or Type Quantity Conventional Alarm or Supervisory Sensing Technology Manual Pull Stations 1 ADDRESSABLE ALARM 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 2 WHEELOCK HSW EXCEDER Combination Audible and Visible 1 WHEELOCK STWC EXCEDER 10. SYSTEM CONTROL FUNCTIONS Type Quantity Hold-Open Door Releasing Devices N/A HVAC Shutdown N/A Fire/Smoke Dampers N/A Door Unlocking N/A Elevator Recall N/A Elevator Shunt Trip N/A 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. Signed: Printed name: GRAM MCCLOUD Date: 10/25/2017 Organization: WSFP Title: ALARM AND DETECTION Phone: 971.303.3551 12.2 System Operational Test This system as specified herein has tested according to all NFPA standards cited herein. Signed: Printed name: GRAM MCCLOUD Date: 10/25/2017 Organization: WSFP Title: ALARM AND DETECTION Phone: 971.303.3551 12.3 Acceptance Test Date and time of acceptance test: 10/25/2017 Installing contractor representative: GRAM MCCLOUD Testing contractor representative: GRAM MCCLOIUD Property representative: JASON MCKINNEY AHJ representative: CITY OF TIGARD JEFF GROVE 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)