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Report (66)
SYSTEM RECORD OF COMPLETION t0 .\ 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: 0.6/f 6 / 1< Supplemental Pages Attached: 1. PROPERTY INFORMATION Name of property: (UPI SUW1e.r Cc ILA or .av ,. !.‘3 Address: \22. S e1 Q 9+' " . c r c„,1 /'1 Description of property: Car 6 77C„C � 'C 1 Name of property representative: 59 C ; � C J r p✓ �r - (,ACA^ C r r* G Address: A01 (70, 'vt'r) Looc, 2,c-0, tc c ca A 9Ef}C � Phone: Fax: E-mail: 2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION r Installation contractor: 1 ;a: ° p 0s` Oc Address: 6 ke_v\et,/ w� w'�G. ©d L-a CD ', Phone: S 03- �! -0130 Fax: S 3 E-mail: .A P Service organization: .S`G,'ti'!"c_ Address: Phone: Fax: E-mail: Testing organization: ''e,(C Address: Phone: Fax: E-mail: Effective date for test and inspection contract: Monitoring organization: ea e L Address: 72-0 OF F.(a,t cf e rS .S.a- 'n D ", :. c' 6rJo,y 723 Phone: S 0-3_-2_35— /400c) Fax: E-mail: Account number: -3 SO© C) Phone line 1: So 3-5 C1 - ;0 Phone line 2: SO -i C+ Means of transmission: lc s S Entity to which alarms are retransmitted: V i3c cc, r sc a Phone: 5c,-; 3. DOCUMENTATION On-site location of the required record documents and site-specific software: ;,W ` , Cyn 4. DESCRIPTION OF SYSTEM OR SERVICE This is a: 0 New system ',Modification to existing system Permit number: °'c-oT NFPA 72 edition: '2-0 4.1 Control Unit Manufacturer: FG T Model number: J 4.2 Software and Firmware Firmware revision number: V--L 3 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 Input voltage of control panel: 12-0 J Control panel amps: 2- C) Overcurrent protection: Type: BCS t r Amps: ZC� Branch circuit disconnecting means location: (a0r'1 Number: 2 A ^5 t 5.1.2 Secondary Power (� Type of secondary power: ti CJCQA c_; A r^/ Location,if remote from the plant: A- P,L}G p Calculated capacity of secondary power to drive the system: In standby mode(hours): TZ k In alarm mode(minutes): 3 5.2 Control Unit ❑ This system does not have power extender panels ❑ Power extender panels are listed on supplementary sheet A ct_7_ 6. CIRCUITS AND PATHWAYS Pathway Type Dual Media Pathway Separate Pathway Class Survivability Level Signaling Line Device Power Initiating Device Notification Appliance Other(specify): 7. REMOTE ANNUNCIATORS N/A Type Location 8. INITIATING DEVICES IJ/h 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 Visible 7j 3 Combination Audible and Visible 'Z Z e 4c 10. SYSTEM CONTROL FUNCTIONS f /A Type Quantity Hold-Open Door Releasing Devices HVAC Shutdown Fire/Smoke Dampers Door Unlocking Elevator Recall Elevator Shunt Trip 11. INTERCONNECTED SYSTEMS El 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 herei has been installed according to all NFPA standards cited herein. Signed: ' Printed name: rvi Date: (''S ',' Organization: :].�- t^^o ' y c( '"6 4-(,-) Title: Phone: ..)- 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. 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. Form Completion Date: 06 r(6//6 Supplemental Pages Attached: 1. PROPERTY INFORMATION Name of property: Co So ry r Ce k)1C f' So;12-1.--14 � Cpi i1 q C Address: 12-1.--14� ! Se"i4k Ave. IT q¢rt�fP�Q C ✓1 Description of property: p M mP c c p v Name of property representative: SDC- r�, G(�( Cpm•( C Address: 1O I Cc—or—i1: G S 2 6 4 4160.r , �f 4ne;scc‘ , C-A 9u II I Phone: Fax: E-mail: 2. INSTALLATION, SERVICE,TESTING,AND MONITORING INFORMATION Installation contractor: Tn,'- r 1 r IDS;•\-Or- 1 ," Address: S 2C 3 Lc �. ec�1 F d c) . i C ( 0 0, k .,5 to,J t^C eh 77°35 Phone: SC?-6 2?. 0I 0 c) Fax: 5o3 27-c)l( 0 E-mail: M•c-�CCI C� ' o;. ✓v'±Un --c r Cc,v'h Service organization: Sco'n Address: Phone: Fax: E-mail: Testing organization: C Address: Phone: Fax: E-mail: Effective date for test and inspection contract: Monitoring organization: 2f'p*C C Address: 7 Z-C) cnejc ` t QC)(:) �Cr-� t2f I c, user 4 r `t 723 2 n Phone: 50-2, - G-3S_ 0OO Fax: E-mail: Account number: �j 50 ';11 Phone line 1: T-(3G-✓6 g 3 Phone line 2: 11, % Means of transmission: P OTS Entity to which alarms are retransmitted: ' 's q a.f` ;CC. sr, S c J t Phone: S 03— 2 S - I SOO 3. DOCUMENTATION V 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: PS 2_614— DCS$ NFPA 72 edition: ZO\3 4.1 Control Unit Manufacturer: ` Model number: 7(QG 4.2 Software and Firmware Firmware revision number: j— l' 4.3 Alarm Verification EA 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 Input voltage of control panel: ZD v Control panel amps: 28 Overcurrent protection: Type: D re5 L<Gf Amps: 20 Branch circuit disconnecting means location: T-1—R a Number: 2 A-6 5.1.2 Secondary Power p / Type of secondary power: LCA 4 G Ct CJS Location,if remote from the plant: A}— -4C? 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 F L . Z a\GC 4,c. (-00, 6. CIRCUITS AND PATHWAYS Pathway Type Dual Media Pathway Separate Pathway Class Survivability Level Signaling Line Device Power Initiating Device Notification Appliance Other(specify): 7. REMOTE ANNUNCIATORS NJ/P. Type Location 8. INITIATING DEVICES N 1 Q� 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 Visible 3 2- t,-j\--,c s c(� Combination Audible and Visible 2 6 L,;‘,)Qttoc, 10. SYSTEM CONTROL FUNCTIONS N� Type Quantity Hold-Open Door Releasing Devices HVAC Shutdown Fire/Smoke Dampers V Door Unlocking Elevator Recall Elevator Shunt Trip 11. INTERCONNECTED SYSTEMS ja_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: Iv1:G�C e Ola r; cle) Date: Q CAC/1 o Organization: ?O;n4- Ypn:}or CCrp Title: A Ce Y)i ePhone: .S02-3/Cl- .36*.2 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.