Report (113) WxLts*Dt
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SYSTEM RECORD OF COMPLETION C ((IL
This form is to be completed by the system installation contractor at the time of system acceptance and approval.
It shall be permitted to modifil 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: 12-18-18 Supplemental Pages Attached:
1. PROPERTY INFORMATION
Name of property: New Horizons Wellness
Address: 13333 SW 68th Parkway
Description of property: Commercial
Name of property representative:
Address:
Phone: Fax: E-mail:
2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION
Installation contractor: Western States Fire Protection
Address: 17500 SW 65Th Ave, Lake Oswego, OR 97035
Phone: 503-657-5155 Fax: E-mail:
Service organization:
Address:
Phone: Fax: E-mail:
Testing organization: Western States Fire Protection
Address: 17500 SW 65Th Ave, Lake Oswego, OR 97035
Phone: 503-657-5155 Fax: E-mail:
Effective date for test and inspection contract:
Monitoring organization:
Address:
Phone: Fax: E-mail:
Account number: Phone line 1: Phone line 2:
Means of transmission:
Entity to which alarms are retransmitted: Central Station Phone:
3. DOCUMENTATION
On-site location of the required record documents and site-specific software: Document box
4. DESCRIPTION OF SYSTEM OR SERVICE
This is a: (a New system 0 Modification to existing system Permit number:
NFPA 72 edition: 2014
4.1 Control Unit
Manufacturer: Silent Knight Model number: 5820x1
4.2 Software and Firmware
Firmware revision number:
4.3 Alarm Verification (a This system does not incorporate alarm verification.
Number of devices subject to alarm verification: Alarm verification set for seconds
Copyright Ca 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)
6. SYSTEM POWER
5.1 Control Unit
5.1.1 Primary Power
Input voltage of control panel: 120v Control panel amps: 6
Overcurrent protection: Type: Brkr Amps: 20
Branch circuit disconnecting means location: Number:
5.1.2 Secondary Power
Type of secondary power: SLA batteries
Location,if remote from the plant:
Calculated capacity of secondary power to drive the system:
In standby mode(hours): 24 In alarm mode(minutes): 5
5.2 Control Unit
0 This system does not have power extender panels
D 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 B
Device Power B
Initiating Device B
Notification Appliance B
Other(specify):
7. REMOTE ANNUNCIATORS
Type Location
SK Front entry
8. INITIATING DEVICES
Addressable or
Type Quantity Conventional Alarm or Supervisory Sensing Technology
Manual Pull Stations 0 Addressable Alarm
Smoke Detectors 7 Addressable Alarm Photo
Duct Smoke Detectors 0
Heat Detectors
Gas Detectors
Waterflow Switches
Tamper Switches
Copyright 02012 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 Horns
Visible 16 Strobes
Combination Audible and Visible 5 H/S
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
0 This system does not have interconnected systems.
0 Interconnected systems are listed on supplementary sheet
12. CERTIFICATION AND APPROV'' S
12.1 System Inst; io Contracto
This system a'sp: if • erein h 4 #•en installed according to all NFPA standards cited herein.
Signed: Printed name: Josh Long Date: 10/8/17
Organizati t. : WSFP Title: A&D technician Phone: 503-502-06(
12.2 System Operational Test
This system as specified herein has tested according to all NFPA standards cited herein.
Signed: Printed name: Date:
Organization: Title: Phone:
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.