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Report (17) Fi=c•I tot-- L'c, SYSTEM RECORD OF COMPLETION 3 � , 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: —3 ,(q Supplemental Pages Attached: I 1. PROPERTY INFORMATION Name of property: Heritage Bank-Bridgeport Center Address: 7632 SW Durham Rd.Suite 120 Tigard,OR 97224 Description of property: Office on 1'floor of 4-story office building Name of property representative: Address: Phone: Fax: E-mail: 2. INSTALLATION, SERVICE,TESTING,AND MONITORING INFORMATION Installation contractor: Point Monitor Corp. Address: 5863 Lakeview Blvd.Suite 100 Lake Oswego,OR 97035 Phone: 503-627-0100 Fax: E-mail: Service organization: HSI Address: Phone: 603-"K3 io- Y 2'6 Fax: E-mail: Testing organization: HSI Address: Phone: Fax: E-mail: Effective date for test and inspection contract: Existing Monitoring organization: HSI Address: Phone: Fax: E-mail: Account number: 1{-``ji-51 4 C2 Phone line 1: Phone line 2: Means of transmission: AES Radio Entity to which alarms are retransmitted: Phone: 3. DOCUMENTATION On-site location of the required record documents and site-specific software: With documents above FACP 4. DESCRIPTION OF SYSTEM OR SERVICE This is a: ❑New system ®Modification to existing system Permit number: FPS2019-00028 NFPA 72 edition: 2016 4.1 Control Unit x5'f"/ i/ Manufacturer: F-61- Model number: -7100 -")._D 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. 1 ;t SYSTEM RECORD OF COMPLETION (continued) 5. SYSTEM POWER Xf ! 5.1 Control Unit 5.1.1 Primary Power Input voltage of control panel: 1 e). Control panel amps: Overcurrent protection: Type: l3dei.ker Amps: Branch circuit disconnecting means location: R Number: -36t 5.1.2 Secondary Power 2LocaType of secondary power: cL V $A Q -e reg a-- Location, tion,if remote from the plant: Calculated capacity of secondary power to drive the system: In standby mode(hours): In alarm mode(minutes): `J 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 Initiating Device Notification Appliance g 1 Other(specify): 7. REMOTE ANNUNCIATORS AM Type Location 8. INITIATING DEVICES N/A 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 1 Wheelock Exceeder SW Combination Audible and Visible 1 Wheelock Exceeder HSW 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 . specifi d herein has been installed according to all NFPA standards cited herein. Signed: 411� ;: Printed name: Jason Devine Date: 03/25/19 Organizar� Point Monitor Corp. Title: Technician Phone: 503-627-0100 12.2 System Operational Test This system as speci ed herein has tested according to all NFPA standards cited herein. Signed: ftil Printed name: Jason Devine Date: 03/25/19 Organization: Point Monitor Corp. Title: Technician Phone: 503-627-0100 12.3 Acceptance Test n �/ Date and time of acceptance test: 3 - .Le- 1 q ! '`004. Installing contractor representative: �a56n -7e-on r, rM C 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. NOTIFICATION APPLIANCE POWER PANEL SUPPLEMENTARY RECORD OF COMPLETION This form is a supplement to the System Record of Completion.It includes a list of types and locations of notification appliance power extender panels. 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. Form Completion Date: " —)-(0 t 1 Number of Supplemental Pages Attached: 1. PROPERTY INFORMATION Name of property: Heritage Bank-Bridgeport Center Address: 7632 SW Durham Rd.Suite 120 Tigard,OR 97224 2. NOTIFICATION APPLIANCE POWER EXTENDER PANELS- i-gCiS+i r� Make and Models Location Area Served rl Power Source 5I 1644-Knit {- 9415 Electrical/FACP Room Floor 1 See Main System Record of Completion for additional information,certifications,and approvals. 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.