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Report Ca(o5o SW Rebvie000 el_Rzo19-co !7Z 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 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: /O. 7. / ! Supplemental Pages Attached: 1. PROPERTY INFORMATION Name of property: 4/0iV S RECet) 1-r/N t AMob ST/+FFf/V 6 Address: 66 SO s W RED cacao 1-N 71 iSAR l6 ,o'? 97zZ y Description of property: Name of property representative: Address: Phone: Fax: E-mail: 2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION Installation contractor: Po/N r mo/./{Tog. CIOQ1SOzA7-IoN Address: 5863 LAKE V 1E w Roth h # /00 AAI/CE QSW 54 Q� DIP 9703. Phone: 503' . 627. O/OO Fax: S-03.ea7.O(10 E-mail: Service organization: 54•44E Address: Phone: Fax: E-mail: Testing organization: POmfr MON/TO,e E.°/?P0/Z/QY/*Al Address: Phone: Fax: E-mail: Effective date for test and inspection contract: .rT�¢ Monitoring organization: A/4 6?( 3ee f//Z/ •1—'' Address: p Phone: 1. 877. g /9•etxV Fax: E-mail: STAAI Ley CSS •Gan? Account number: Phone line 1: Phone line 2: Means of transmission: #465 R4 /Q Entity to which alarms are retransmitted: Phone: 3. DOCUMENTATION 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: e70/9 00/72 NFPA 72 edition: ZO/ 4.1 Control Unit EY 1sT/N6 Manufacturer: Si I ENT KN/r i- Model number: SZD3 4.2 Software and Firmware J Firmware revision number: REV V 4.3 Alarm Verification 0 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. it r SYSTEM RECORD OF COMPLETION (continued) 5. SYSTEM POWER 5.1 Control Unit 5.1.1 Primary Power Input voltage of control panel: FZb Y4G Control panel amps: Overcurrent protection: Type: Amps: D Branch circuit disconnecting means location: E(�_ (gym Number: 4f j I- 8 5.1.2 Secondary Power Type of secondary power: I 2 �/ �. d 411 ff84. 2•t s (1(s 1 Location,if remote from the plant: /I1! Po ze vhf Calculated capacity of secondary power to drive the system: In standby mode(hours): Ly In alarm mode(minutes): 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 Other(specify): 7. REMOTE ANNUNCIATORS N/4 Type Location 8. INITIATING DEVICES A 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 f ( pe/ER W '`_ /bek txr ee Se c Visible 7 COoppC WIkE(ocK EXG61>FL SERIFS Combination Audible and Visible 3 10. SYSTEM CONTROL FUNCTIONS A//4 Type Quantity Hold-Open Door Releasing Devices HVAC Shutdown Fire/Smoke Dampers Door Unlocking Elevator Recall Elevator Shunt Trip 11. INTERCONNECTED SYSTEMS IAThis 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 s ecified herein h been installed according to all NFPA standards cited herein. Signed: ,4 h/% rrt ..- Printed name: A'l/l�a�f/IP. /, /la+ia Date: /0. 7• /9 Organization: Omer'440,v,rike ago Title: LFA flrC/h/ mar . Phone: 363,3S/. 9, air , 12.2 System Operational Test This system as s ecified hereinhastested according to all NFPA standards cited herein. Q Signed: /�C> /r//lvfen-A-14 ► Printed name: nunigeI R. riiit tt 4I1 Date: /©.-7. 1 1 Organization: /�c vi 70Q Car Title: 4E4,/V/CPT Q recki Phone: .S 3.3s/. 9SL(. 12.3 Acceptance Test Date and time of acceptance test: /0. 7- /9 6.t90 4444 Installing contractor representative: Testing contractor representative: Property representative: AHJ representatives 45: r N-' y ip "`-s.- ( i`t" rr 1'' if s ,-4,._, ,w,. 5 7 )9, / / , 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: 10.7. /1 Number of Supplemental Pages Attached: 1. PROPERTY INFORMATION Name of property: /j 40-siS far Ru .4+��b S-7"QFF1/y Address: (D 6 SO 5 W i C6 woo 5 4 -fi cSoz P d/2 `h 2Z)( 2. NOTIFICATION APPLIANCE POWER EXTENDER PANELS Make and Model Location Area Served Powpr Source Po rrg�� 2 ins PA Moot zN4 F 1, i 1..a - 8 ps/y 406, kc- kooixt See Main System Record of Completion for additional information,certifications,and approvals. 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. (F,.