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Report 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: ( N/t Cp/c 7 Supplemental Pages Attached: ...---"- 1. PROPERTY INFORMATION Name of property: liktAk O. &kW r of Address: 129 0 9 S kI 68.4- f kw7 t Z !D Description of property: k)4i CQ, UV(3I At Name of property representative: PAC 772-0 S Address: Phone: Fax: E-mail: 2. INSTALLATION, SERV CE,TESTING,AND MONITORING INFORMATION Installation contractor: rd 1ei ' /Ito yl r -Or- Address: JOG 3 1A!.eV I+P LTJ 8/✓d) ',� 44-G ©S4,A, Phone: 5`03 2'' -0//0 C)�Fa�x: E-mail: _ Service organization: ylia t,� _ I' t Address: Phone: Fax: E-mail: Testing organization: ci"3 4 Q1 Address: 7' Phone: Fax: E-mail: Effective date for test and inspection contract:: Monitoring organization: /Va Cjd' 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: 4. DESCRIPTION OF SYSTEM OR SERVICE This is a: 0 New system Modification to existing system Permit number: f P� 17 c0 ry 7' NFPA 72 edition: Zv III 4.1 Control Unit Manufacturer: v1 (SiL(4,-7/ Model number: 58 d 6 4.2 Software and Firmware ll Firmware revision number: ,' t 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. 1 •T . SYSTEM RECORD OF COMPLETION (continued) 5. SYSTEM POWER 5.1 Control Unit 5.1.1 Primary Power Input voltage of control panel: yLoo Control panel amps: Overcurrent protection: Type: CW-_K Amps: 2-0 Branch circuit disconnecting means location: Number: 5.1.2 Secondary Power Type of secondary power: ' '2fc _) Location,if remote from the plant: Calculated capacity of secondary power to drive the system: In standby mode(hours): In alarm mode(minutes): 5.2 Control Unit D02- id7,`eLs ❑ This system does not have power extender panels IS' / (-?`""P'H P ' ❑ Power extender panels are listed on supplementary sheet A A t L l L C k -'/4 1-d T s L;cl 5 6. CIRCUITS AND PATHWAYS Aii9 ck.&k t Pathway Type Dual Media Pathway Separate Pathway Class Survivability Level Signaling Line Device Power Initiating Device Notification Appliance 13 Other(specify): 7. REMOTE ANNUNCIATORS AleA„ Type Location 8. INITIATING DEVICESMO / /`) 6 ADD' 1-1( d $ �essable 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. SYSTEM RECORD OF COMPLETION (continued) 9. NOTIFICATION APPLIANCES Type Quantity Description Audible Visible 3 sf e64.4 s ys 1&"1 s cc-)so Z Combination Audible and Visible 3 ger y, ied jj.e, $Y.5 S r e 10. SYSTEM CONTROL FUNCTIONS Aj O S Type Quantity Hold-Open Door Releasing Devices HVAC Shutdown Fire/Smoke Dampers Door Unlocking Elevator Recall Elevator Shunt Trip 11. INTERCONNECTED SYSTEMS A] GVe401/43)4 ,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. ilk Signed: Kuh 161)I Printed name: K.t rt h �Q1)iA Date: t7 Organization: Po t4+ Atil '-pd' Title: re Phone: " 3 12.2 System Operational Test rt.! a 7..d/dj This system a ypecifi herein has tested according to all NFPA standards cited herein. Signed: Printed name: C4(1'5 eofiti Date: I d / Z `/1 7 Organization: /kirPud Ariz/ C4f p Title: t4 e 144 Phone: 3 1 2 51 12.3 Acceptance Test Date and time of acceptance test: ; /z ` i 6 'd� 41 Installing contractor representative: 7 k/6 ,J Testing contractor representative: Property representative: AHJ representative: C,G7X b l 67/TIL-P C L O c? 7/ti 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. 1