Report (60) t- s ac\c(,- CO 1 ?1U1
SYSTEM RECORD OF COMPLETION i ,
This form is to be completed by the system installation contractor at the time of system acceptance and approval. `T .
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: 1117/18 Supplemental Pages Attached: 0
1. PROPERTY INFORMATION
Name of property: CYPRESS
Address: 10220 SW GREENBURG RD 417 TIGARD,OR
Description of property: SERVER ROOM
Name of property representative: JOHN DEBUGE
Address: 'SAME AS ABOVE
Phone: Fax: E-mail: john.debuge@cypress.com
2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION
Installation contractor: SUPPRESSION SYSTEMS,INC.
Address: 7715 NE 33RD DRIVE,SUITE E PORTLAND,OR 97211
Phone: 503.233.4582 Fax: E-mail: jeremy@suppression_com
Service organization: SAME AS ABOVE
Address: N/A
Phone: N/A Fax: N/A E-mail: N/A
Testing organization: SAME AS ABOVE
Address: NIA
Phone: N/A Fax: N/A E-mail: N/A
Effective date for test and inspection contract: 11/1/18
Monitoring organization: BUILDING FIRE ALARM SYSTEM
Address:
Phone: Fax: E-mail:
Account number: Phone line 1: Phone line 2:
Means of transmission: BUILDING SYSTEM DACT
Entity to which alarms are retransmitted: N/A Phone:
3. DOCUMENTATION
On-site location of the required record documents and site-specific software: SUPPRESSION SYSTEM DOCUMENT BOX
4. DESCRIPTION OF SYSTEM OR SERVICE
This is a: ®New system ❑Modification to existing system Permit number: FPS2018-00126
NEPA 72 edition: 2013
4.1 Control Unit
Manufacturer: AUTOPULSE Model number: 542R/E
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 0 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: 120VAC Control panel amps: 7
Overcun-ent protection: Type: CIRCUIT BREAKER Amps: 20
Branch circuit disconnecting means location: SERVER RM ELEC PNL Number: LOCKED OUT
5.1.2 Secondary Power
Type of secondary power: SLA BACKUP BATTERY
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): 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
Device Power B 1
Initiating Device B 1
Notification Appliance B 1
Other(specify):
ACTUATOR B 1
7. REMOTE ANNUNCIATORS
Type Location
8. INITIATING DEVICES
Addressable or
Type Quantity Conventional Alarm or Supervisory Sensing Technology
Manual Pull Stations 1 , CONVENTIONAL ALARM DUAL ACTION
Smoke Detectors 2 CONVENTIONAL ALARM PHOTO
Duct Smoke Detectors
Heat Detectors
Gas Detectors
Waterflow Switches
•
Tamper Switches 1 CONVENTIONAL SUPERVISORY RELEASING MONITOR
Copyright 0 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.
_. lK
SYSTEM RECORD OF COMPLETION(continued)
9. NOTIFICATION APPLIANCES
Type Quantity Description
Audible 1 ALARM BELL
Visible 1 RELEASE STROBE
Combination Audible and Visible 1 HORN/STROBE
10. SYSTEM CONTROL FUNCTIONS
Type Quantity
Hold-Open Door Releasing Devices
HVAC Shutdown
Fire/Smoke Dampers
Door Unlocking
Elevator Recall
Elevator Shunt Trip
11. INTERCONNECTED SYSTEMS
121 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: Jeremy Whisenhunt Date: 11/6/18
Organization: SSI Title: TECHNICIAN Phone: 503.961.2099
12.2 System Operational Test
This system as specified herein has tested according to all NFPA standards cited herein.
Signed: Printed name: Jeremy Whisenhunt Date: 11/6/18
Organization: SSI Title: TECHNICIAN Phone: 503961.2099
12.3 Acceptance Test
Date and time of acceptance test: 11/6/18
Installing contractor representative: JEREMY WHISENHUN �"�-
Testing contractor representative:
Property representative: JOHN DE UGE
AHJ representative: _ -
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.