Report (13) y • 219
(906
SYSTEM RECORD OF COMPLETION
This form is to he 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 JW4 in all unused lines.
Attach additional sheets, data,or calculations as necessary to provide a complete record.
Form Completion Date: 5/23/2019 Supplemental Pages Attached: 0
1. PROPERTY INFORMATION
Name of property: LINCOLN TOWER
Address: 10260 SW GREENBURG RD PORTLAND,OR 97223
Description of property: COMMERCIAL HIGH RISE
Name of property representative: SHORENSTEIN PROPERTY MANAGEMENT
Address: SAME
Phone: Fax: E-mail:
2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION
Installation contractor: CAPITOL ELECTRIC
Address:
Phone: Fax: E-mail: _
Service organization: Johnson Controls Fire
Address: 6305 SW Rosewood St Lake Oswego,OR 97035
Phone: 503-683-9000 Fax: 503-675-6521 E-mail:
Testing organization: Johnson Controls Fire
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: existing
Monitoring organization:
Address:
Phone: Fax: E-mail:
Account[umber: WITH CUSTOMER Phone line I: RADIO Phone line 2: RADIO
Means of transmission: RADIO
Entity to which alarms are retransmitted: Phone:
3. DOCUMENTATION
On-site location of the required record documents and site-specific AT FACP
software:
4. DESCRIPTION OF SYSTEM OR SERVICE
This is a: ❑New system ®Modification to existing system Permit number:
NFPA 72 edition:
4.1 Control Unit
Manufacturer: SIMPLEX Model number; 4100U
4.2 Software and Firmware
Firmware revision number: 12.03.04
4.3 Alarm Verification 02 This system does not incorporate alarm verification.
Number of devices subject to alarm verification: Alarm verification set for seconds
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.
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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: 10
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): 15
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 N/A YES 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 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 safe or distribut on.
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SYSTEM RECORD OF COMPLETION(continued)
9. NOTIFICATION APPLIANCES
Type Quantity Description
Audible - -
Visible 15 RED WALL MOUNT,CEILING MOUNT FIRE
Combination Audible and Visible •
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 NEPA standards cited herein.
Signed: Printed Date:
name:
Organization: Title: Phone:
12.2 System Operational Test
This system as specified herein haslested according to all NEPA standards cited herein.
Signed: Printed JASON JACKSON Date:
name:
Organization: JOHNSON CONTROLS FIRE Title: Tech Rep Phone: 503-683-9000
12.3 Acceptance Test
Date and time of acceptance test:
Installing contractor
representative:
Testing contractor representative:
Property representative:
AK)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.