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Report (94) 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.ti Form Completion Date: 2.—Z- — O Supplemental Pages Attached: v ) 1. PROPERTY INFORMATION- D - Name of property: T 1 Address: 4 Z_I $4n/ 6 Pkwy Description of property: ___Lervt1 v \jJ t_.4‘01 /A .4 4_ Nameof property representative: !/ ` Address: S caikLQ Phone: Fax: E-mail: 2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION Installation contractor: Po Ih llT /4 Obn)Tar Address: (] 7 Lk'ty fj Ivi - Phone: I 503 627 010o Fax: t^ E-mail: Service organization: We 54-0 eh r1'C' _pro F'.e c4'f,a vv Address: Phone: Fax: E-mail: t'� Testing organization: W-GS 1--pl^h �1�/�"'t_ Pro Peal' Address: Phone: Fax: E-mail: Effective date for test and inspection contract: Monitoring organization: k ro rlsOil 4-U4i Y,7' Address: // Phone: Col '27 '3 J $ Fax: E-mail: Account number: IC')(� 7 Phone line 1: Phone line 2: Means of transmission: l'J..11'&4.. Entity to which alarms are retransmitted: Phone: 3. DOCUMENTATION B (� On-site location of the required record documents and site-specific software: (( Cl."P"J c.. . 4. DESCRIPTION OF SYSTEM OR SERVICE (� /' This is a: ❑New system Modification to existing system Permit number: cps 2o17- c yfr NFPA 72 edition: "LD 19 4.1 Control Unit Manufacturer: E51- 2- Model number: 4.2 Software and Firmware Firmware revision number: 4.3 Alarm Verification ig 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 •4 • SYSTEM RECORD OF COMPLETION (continued) 5. SYSTEM POWER 5.1 Control Unit 5.1.1 Primary Power Input voltage of control panel: ( Wil Control panel amps: Overcurrent protection: Type: ice vet, Amps: Branch circuit disconnecting means location: Z Pt- 2 ( 4) Number: 3. 5.1.2 Secondary Power g'01—,try Type of secondary power: V 01-,.Cry/ Location,if remote from the plant: r Calculated capacity of secondary power to drive the system: In standby mode(hours): 2, In alarm mode(minutes): 5- 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 /30.C '1.4-Ai`Q-Q/1 Device Power t��!( Initiating Device Notification Appliance Other(specify): 7. REMOTE ANNUNCIATORS Type MO. C./411k Location 8. INITIATING DEVICES Addressable or Type Quanti Conventional Alarm or Supervisory Sensing Technology A Manual Pull Stations !Vw 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 Combination Audible and Visible 1 0 10. SYSTEM CONTROL FUNCTIONS Type // Quantity Hold-Open Door Releasing Devices /JD C!/W^w � . HVAC Shutdown o Fire/Smoke Dampers Door Unlocking Elevator Recall Elevator Shunt Trip 11. INTERCONNECTED SYSTEMS pThis system does not have interconnected systems. 0 Interconnected systems are listed on supplementary sheet 12. CERTIFICATION AND APPROVALS 12.1 System Installation Contractor This system as s ecified herei has been installed according to all NFPA standards cited herein. t Signed: �^(� ) Printed name: ori i/1 F / f1 Date: 2 -2T-T- f Organization: R d,A+ An o,,,1 .g Title: .;4 rj // /-I o N pech Phone: 17/. 3170q• STr7 12.2 System Operational Test t This system as specified herein has tested according to all NFPA standards/� cited herein. f Signed: .L Printed name: /`/(`/h /?/N Date: 2 —2 < /7 Organization: Tc ,4" Phone: 97I • 374'-5757 12.3 Acceptance Test Date and time of acceptance test: Installing contractor representative: Testing contractor representative: Property representative: AHJ representative: Copyright CO 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.