Report zoig-
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: 4-25-18 Supplemental Pages Attached: n
1. PROPERTY INFORMATION
Name of property: Lincoln/Suite 600
Address: 10220 SW%Greerib irg RD Tigard OR 97223
Description of property: B Business Gr nun
Name of property representative: Shorenstein Reality Services
Address: Same As Above
Phone: - Fax: - E-mail: -
2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION
Installation contractor: Point Monitor Corp
Address: 5803 Lakewiew Elivid Lake Oswego OR 9-7035
Phone: 503-267-91746 Fax: - E-mail: -
Service organization: Same As Bel;ow,
Address: -
Phone: - Fax: - E-mail:
Testing organization: Johnson Controls
Address: =305 SW Rosewood St Lake Oswego: OR. 97035
Phone: 503-683-9000 Fax: 503-675-6521 E-mail: -
Effective date for test and inspection contract: -
Monitoring organization: 4Wantage
Address: -
Phone: - Fax: E-mail: -
Account number: 5220 Phone line 1: Radio Phone line 2: Radio
Means of transmission: .Radio Dialer
Entity to which alarms are retransmitted: - Phone: 1-888-20!0-5298
3. DOCUMENTATION
On-site location of the required record documents and site-specific FACP
P
software:
4. DESCRIPTION OF SYSTEM OR SERVICE
This is a: 0 New system ®Modification to existing system Permit number: installer Holds Permit
NFPA 72 edition: 2013
4.1 Control Unit
Manufacturer: Si;plea Model number: 4100IU
4.2 Software and Firmware
Firmware revision number: 1_.06.09
4.3 Alarm Verification ®This system does not incorporate alarm verification.
Number of devices subject to alarm verification: 0 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.
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SYSTEM RECORD OF COMPLETION (continued)
5. SYSTEM POWER
5.1 Control Unit
5.1.1 Primary Power
Input voltage of control panel: Existing;Unchanged Control panel amps: -
Overcurrent protection: Type: Amps: -
Branch circuit disconnecting means location: - Number:
5.1.2 Secondary Power
Type of secondary power: Batteries :mer alcor existing changed
Location,if remote from the plant: -
Calculated capacity of secondary power to drive the system:
In standby mode(hours): 24 In alarm mode(minutes): 15
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 0 0
Device Power 0
Initiating Device 0
Notification Appliance 0 B '
Other(specify):
7. REMOTE ANNUNCIATORS
Type Location
Existing. LCD Lobby
8. INITIATING DEVICES
Addressable or
Type Quantity Conventional Alarm or Supervisory Sensing Technology
Manual Pull Stations 0 -
Smoke Detectors
Duct Smoke Detectors u
Heat Detectors u
Gas Detectors ,r -
Waterflow Switches 0 - -
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.
4
SYSTEM RECORD OF COMPLETION(continued)
9. NOTIFICATION APPLIANCES
Type Quantity Description
Audible 0 -
Visible 3 Simplex 4906-9103 Wall:White
Combination Audible and Visible 3 Simplex 4906-9120 9 WaH,`W>>h to
10. SYSTEM CONTROL FUNCTIONS
Type Quantity
Hold-Open Door Releasing Devices 0
HVAC Shutdown 0
Fire/Smoke Dampers 0
Door Unlocking 0
Elevator Recall 0
Elevator Shunt Trip 0
11. INTERCONNECTED SYSTEMS
0 This system does not have interconnected systems.
® Interconnected systems are listed on supplementary No
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: Date: 2Il
Kirin 4-�_v�-1:1
Organization: Point Monitor Title: Phone:
12.2 System Operational Test
This system as specified herein has tested according to all NFPA standards cited herein.
Signed: Printed name: R S,vatski Date: 4-25-18
Organization: Johnson Con:!ro g Title: !nstater Phone: 03-683-9000
12.3 Acceptance Test
Date and time of acceptance test: 4-27-18 M 5:s •
Installing contractor
representative:
Testing contractor representative: Robert Swateki
Property representative:
AHJ representative: )Cif C(Fti G L Ft(' ph
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.
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