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Report (28) 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: 11/01/2019 Supplemental Pages Attached: 1 1. PROPERTY INFORMATION Name of property: Oregon Academy of General Dentistry(at Triangle Pointe) Address: 13333 SW 68th Parkway Ste.010 Tigard,OR 97233 Description of property: Lower level educational space in multi-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.#100, Lake Oswego,OR 97035 Phone: 503-627-0100 Fax: E-mail: Service organization: Address: Phone: Fax: E-mail: Testing organization: Same as above Address: Phone: Fax: E-mail: Effective date for test and inspection contract: Monitoring organization: Central Station Monitoring Address: Phone: 800-722-0364 Fax: E-mail: Account number: 14-9378 Phone line 1: Phone line 2: Means of transmission: I ntity to which alarms are retransmitted: Phone: 3. DOCUMENTATION On-site location of the required record documents and site-specific software: Table by FACP 4. DESCRIPTION OF SYSTEM OR SERVICE This is a: ®New system ❑Modification to existing system Permit number: FPS2019-00078 NFPA 72 edition: 2016 4.1 Control Unit Manufacturer: Silent Knight Model number: 5820XL 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 m 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 f3) 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: Overcurrent protection: Type: Breaker Amps: Branch circuit disconnecting means location: 1-D Number: 42 5.1.2 Secondary Power Type of secondary power: 12V18Ah batteries x2 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 E 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 B 1 Device Power Initiating Device B 1 Notification Appliance B 1 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 4 Addressable Alarm Photo 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. ( . 2of3) • SYSTEM RECORD OF COMPLETION (continued) 9. NOTIFICATION APPLIANCES Type Quantity Description Audible Visible 8 Kidde EG1 F-VM/EGCF-VM Combination Audible and Visible 8 Kidde EG1 F-HDVM/EGCF-HDVM 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. O Interconnected systems are listed on supplementary sheet 12. CERTIFICATION AND APPROVALS 12.1 System Installation Contractor This syste s speci ed herein has been installed according to all NFPA standards cited herein. Signed: Printed name: Jason Devine Date: 11/01/2019 Organi ion: Point Monitor Corp. Title: Technician Phone: 503-627-0100 12.2 System Operational Test This syste speci d herein has tested according to all NFPA standards cited herein. Signed: Printed name: Jason Devine Date: 11/01/2019 Organiz tion: Point Monitor Corp. Title: Technician Phone: 503-627-0100 12.3 Acceptance Test Date and time of acceptance test: 11/01/2019 6:00am Installing contractor representative: Jason Devine Testing contractor representative: Jason Devine Property representative: AHJ representative: Jeff Grove 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. (p. of 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: 11/01/2019 Number of Supplemental Pages Attached: 1 1. PROPERTY INFORMATION Name of property: Oregon Academy of General Dentistry(at Triangle Pointe) Address: 13333 SW 68th Parkway Ste.010 Tigard,OR 97233 2. NOTIFICATION APPLIANCE POWER EXTENDER PANELS Make and Model Location Area Served Power Source Edwards BPS(NAC1) Fl. 1 Electrical/FACP Fl.G 1-D#42 Edwards BPS(NAC2) Fl. 1 Electrical/FACP Fl.G/Fl. 1 1-D#42 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. fp. 1 of €„,