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Report (63) io3 Zoi °t - c,-1)f7 SYSTEM RECORD OF tOMPLETION 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: 2/13/2017 Supplemental Pages Attached: 0 1. PROPERTY INFORMATION Name of property: 5 LINCOLN CENTER Address: 10200 SW GREENBURG RD PORTLAND,OR 97223-5510 Description of property: COMMERCIAL OFFICE BUILDING Name of property representative: SHORENSTEIN Address: SAME Phone: Fax: E-mail: 2. INSTALLATION, SERVICE,TESTING,AND MONITORING INFORMATION Installation contractor: Capitol Electric Address: 11401 NE Marx St portland OR,97220 Phone: 503-516--2233 Fax: E-mail: Service organization: Johnson Controls Address: Phone: Fax: E-mail: Testing organization: Johnson Controls Address: 6305 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: Address: Phone: 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 WITH ENGINEERING software: 4. DESCRIPTION OF SYSTEM OR SERVICE This is a: D New system ®Modification to existing system Permit number: NFPA 72 edition: 4.1 Control Unit Manufacturer: SIMPLEX Model number: 41000 4.2 Software and Firmware Firmware revision number: 12.06.09 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. (1" 1 SYSTEM RECORD OF COMPLETION (continued) 5. SYSTEM POWER 5.1 Control Unit 5.1.1 Primary Power Input voltage of control panel: 120 Control panel amps: 3 amps Overcurrent protection: Type: breaker Amps: 20 Branch circuit disconnecting means location: Number: 5.1.2 Secondary Power Type of secondary power: 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 ❑ This system does not have power extender panels 9 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 - Initiating Device Notification Appliance NA NA B 0 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 - - Visible 5 wall mount white fire Combination Audible and Visible 7 wall mount white fire 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 ❑ 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: :::3e.____ Printed „ ` Date: 2� name: /1 n W 1315Ntv✓j 7 20"1.4/el Organization: Capitol Elects Title: Electrician Phone: Sio PS 7$12,5 12.2 System Operational Test This system as specified herein has tested according to all NFPA standards cited herein. Signed: i_ ` Printed Jason Jackson Date: O Za�, name: O Organization: Simpl rinnell Title: Tech Rep Phone: 503-683-9000 12.3 Acceptance Test Q Date and time of acceptance test: 2 - U- 20 , /•--4c,c) io/,,,„ Installing contractor representative: Testing contractor representative: -2-- 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. FY t