Report (29) ~-....., t' .Z o l 9—0c. i 6,
SYSTEM RECORD OF COMPLETION
This form is to be completed by the system installation contractor at the time efsystem acceptance andapproval
it shall be permitted to mod f=thisfarm as needed to provide a more complete and/or clear regard
Insert NIA In all unused liner
Attach additional sheets,data,or calculations as necessary to prowde a complete record
Farm Completion Date: ),/& 1 I Supplemental Pages Attached: 0
i. PROPERTY INFORMAT
ION U
Name of property: iii 47' ID r� fevi.fee cq&7C 3 c e
Address: 7 s �w II7VP, l� l
Description of pmpetty: f s,:4'1' I ' (i0,4- . ' ,3r) Ti , '+"'
Name ofro a7k
p p rty representative:
Address OA A r
Phony N'i' /V
Fax: /A E-mail: NAA;
2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION
Installation contractor: _ C if1 Al.!"11)?t'i
Address: cc' 3 j-a!e v,''IA j RcvJe V J to lze GSwr!RG ok
Phone: S-0 —(7 7'i.I u C Fax: A/7+ E-mail: hrvGG 0 NO-J.01,'k? 1
Service organization: NA
Address: /l//
Phone: A VA" Fax E-mailA! : l"/rT
Testing organization: J/A
. Address; 11,
Phone: 1(1/A Fax: l V/k E-mail: VA'
Effective date for test and vection contract:
Monitoring organization: itht--
Address: ^,
Phone: Fax Fax: 414 E-mail: 7,4
Acwunt number. !V Phone line I: / l/�"' Phone line 2:
Means of transmission:
Entity to which alarms are retransmitted: A
Phone: 1
3. DOCUMENTATION '
On-site iocatton of the required record documents and site-specific software
. 4. DESCRIPTION OF SYSTEM OR SERVICE
This is a: Q New system Nfodification to existing system Permit number: F r)
NEPA 72 edition:. (u/f 1 1
4.1 Control Unit
Manufacturer: -w ___ _210_0__________r
Model number
4.2 Software and Firmware , --
Firmware revision number: r /4
verification set for
i 4.3 Alarm Verification
-13
,This of devices subject to alarm verification: I This system does not incorporate alarm verification.Alam,
"_~------..._ seconds
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SYSTEM RECORD OF COMPLETION(continued)
5. SYSTEM POWER
5.1 Control Unit
5.1.1 Primary Power nI
Input voltage of control panel: I`�V Control panel amps:
overcurrent protection: Type: hAmps: I '1
Branch Circuit disconnecting means location: E t1i' (a U_ g-14/ Number. A/
5.1.2 Secondary Power
Type of secondary power: „ a y 7,1 b/' j
Location,if remote from the plant:
Calculated capacity of secondary power to drive the system:
in standby mode(hours): 2q In alarm mode(minutes): �~
5.2 Control Unit
ID This system does not have power extender panels
O Power extender panels are listed on supplementary sheet A
8. CIRCUITS AND PATHWAYS
Pathway Type Dual Media Pathway Separate Pathway Class Survivability Level
Signaling Line
Device Power
Initiating Device
Notification Appliance
Other lspec)fy).
N..
7. REMOTE ANNUNCIATORS
Type
Location
8. INITIATING DEVICES
Quant} Addressable or
Conventional Alarm or Sutservisro Sensing "ecttncla
Manual Pull StationsY
Smoke Detectors
11
Duct Smoke Detectors �`"
Heat Detectors • 11111111.111
.111111111111111111.
Gas Detectors
Waterflow Switches
Tam+erSwitches11111111111111111111111111111111111111111111111111111111111111111111 \\\.,
0
PQM Daae Naomi Mtn Promotion Association.7 s form may be copied for individual use other than far resale.R may not be copied hn c+stnmar
dot rah At dteusttuaan.
SYSTEM RECORD OF COMPLETION(continued)
9, NOTIFICATION APPLIANCES
Type Quantity I Description
Audible
Visible
Combination Audible and Visible 1 .
A Ar 1/1 S '+tG
10. SYSTEM CONTROL FUNCTIONS
Hold-0•en Door Releasing Devices Type Quantity
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 Iisted on supplementary sheet
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12. CERTIFICATION AND APPROVALS �
12.1 System Installation Contractor
This system specified herein has been installed according to all hIFFA standards cited herein.
Signed:
Printed name: �i te.4 Pt 'iF'iti Date: ►, 1�_
Organization: o�,r �/' f --
Title: Li t Apt Phone
rta— QI-
12.2 System Operational Test
This system as specified herein has tested according to all NFPA standards cited herein.
Signed:
Printed name: 1 t Date 1
Organization: I ► Title: 1 1
Phone , I
12.3 Acceptance Test
Date and time of acceptance test
Installing contractor representative: `~
JueNth1r�7y1
Testing contractor representative: A
Property Tepresentative: j
AHJ representative: