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Report (65) ( �c \c=-3q �'`"1 SYSTEM RECORD OF COMPLETION Lh (tiN 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: �� 2( ($ Supplemental Pages Attached: 1. PROPERTY INFORMATION Name of property: 1 E F 1 Lg 1_03 GROU a Address: (2.9 0 q 5 vJ (fl$ ?RR.KNI4 PO/ ! 2.5 0 "Po LA01)f 0 R Al 12.3 Description of property: O f F 1 C r Name of property representative: Address: Phone: Fax: E-mail: 2. INSTALLATION, SERVICE,TESTING,AND MONITORING INFORMATION Installation contractor: ?p t!JT MO oti-DR, C.0 ft P Address: 546(03 LAKs V 1 f_v3 Zi-\)'O LOO LAKE OSvi fC(4OR °1-10 35. Phone: 5O3" (QZ1 " 0 l vD Fax: 601- (p Ll ' O t t c E-mail: v Service organization: Address: Phone: Fax: E-mail: Testing organization: Address: Phone: Fax: E-mail: Effective date for test and inspection contract: Monitoring organization: S.1-Ar)`�� J`tc.;�?r r`! SZ.i.s «a S Address: Phone: (-1%11 1-VRA2 q%1a 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: C932.Q V? - 00 t NFPA 72 edition: lo($ 4.1 Control Unit Manufacturer: Model number: 4.2 Software and Firmware Firmware revision number: 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. SYSTEM RECORD OF COMPLETION (continued) 5. SYSTEM POWER 5.1 Control Unit 5.1.1 Primary Power A Input voltage of control panel: 1 Zl�J C Control panel amps: Z. Amps: Overcurrent protection: Type: Branch circuit disconnecting means location: i.I+ 'jL'\.:i\l' g.N Number: CV.,:c V a r‘<V••.. Li 5.1.2 Secondary Power Type of secondary power: Location,if remote from the plant: Calculated capacity of secondary power to drive the system: In alarm mode(minutes): In standby mode(hours): 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 Class Survivability Level Pathway Type Dual Media Pathway Separate Pathway Signaling Line Device Power Initiating Device Notification Appliance Other(specify): 7. REMOTE ANNUNCIATORS Type Location 8. INITIATING DEVICES Addressable 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 as Visible t. 510.0%E Combination Audible and Visible t oQ..0 / 579.0 is -3 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 154 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 s cified he ein ha een installed according to all NFPA standards cited herein. rr Signed: �i Printed name: j .c &y SPEER Z Date: ll 1 o l 1$ Organ ion: ?ol1JT 6o \TO Title: ,cs 9. t IMAa Phone: 60 -991-2,Lo 12.2 System Operational Test This system as ecified)erein i.s tested according to all NFPA standards cited herein. Signed: � Printed name: �1ER£1-AY Date: IIIZto I1$ Organ do . ,1 r 0 R. Title: M 0 Phone: 563- 99/-$200 12.3 Acceptance Test Date and time of acceptance test: Installing contractor representative: Testing contractor representative: Property representative: 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.