Report (2) t-7>Szoza--00o7,7
SYSTEM RECORD OF COMPLETION
This form is to be completed by the spstern installation contractor at the time of system acceptance and approval.
It shall be permitted to mods'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: Supplemental Pages Attached:
1. PROPERTY INFORMATION
Name of property: Vim.r i&f t / L t()CO 1 C1 I
Address: O300 Sc G re-e .)10c, 3pct3
Description of property: Q.F,
Name of property representative: etc ne Lock,(yr9 (✓h
Address: N/4 p� ^
Phone: 5O 7Qp 322 . Fax: E-mail:N//C Pk/A
2. INSTALLATION, SERVICE, TESTING, AND MONITORING INFORMATION
Installation contractor: \ T rnon
Address: S 6 3 L A-k'eivi li(A) gl vd
t. -i Lie 05l t)j o )(/ / /61 c
Phone: 627 of po Fax: E-mail: fi AI i tll G fe b (V Poj n-1' (Y)rniior.Gor✓1
Service organization: 1
Address:
Phone: Fax: E-mail:
Testing organization:
Address:
Phone: Fax: 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 software: PA G P
4. DESCRIPTION OF SYSTEM OR SERVICE
This is a: ❑New system tgr,Modification to existins system Pennit number:
NFPA 72 edition: 2,0 I`3)
4.1 Control Unit
Manufacturer: i (1) p le,k Model number: 1-j- 1 OQ
4.2 Software and Firmware /
Firmware revision number:
4.3 Alarm Verification yg.This system does not incorporate alarm verification.
Number of devices subject to alarm verification: Alarm verification set for seconds
Copyright C 2012 National Fire Protection Association.This form may be copied for individual use other than fer resale.It may not be copied forcommercial sale or distribution.
ip. 1 of 3)
SYSTEM RECORD OF COMPLETION (continued)
5. SYSTEM POWER
5.1 Control Unit
5.1.1 Primary Power
Input voltage of control panel: N f A. Control panel amps: N//t
Overcu rent protection: Type: N/ A Amps: 1,N ,4
Branch circuit disconnecting means location: N/A Number: IV /
5.1.2 Secondary Power Type of secondary power: n r
. /V/4
Location.if remote from the plant:
Calculated capacity of secondary power to drive the system:
In standby mode(hours): 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 17 U
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.
(p. 2 of 3)
SYSTEM RECORD OF COMPLETION (continued)
9. NOTIFICATION APPLIANCES _
Type Quantity Description
Audible
Visible G s+m p ) 6x Ca-i 1 nJ crht•d6
Combination Audible and Visible S ce.AI }-lorr +ro be
10. SYSTEM CONTROL FUNCTIONS 1 J
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 ified herein has been installed according to all NFPA standards cited herein.
Signed: n Printed name: Oa M I()IC V �ir Date: I/31 /�p
Organization: Pot n-f-- Mo/l14-7,r Title: Tee6-, Phone: 1 / 3(/2
12.2 System Operational Test
This system a ified herein has tested according to all NFPA standards cited herein. Ren
M /3
Signed: ,1G%� i��� Printed name: /(�f G� Date: l
�M 1 �D
Organization: Poi na ,oni4 r Title: ` Phone: I1 -) /20
12.3 Acceptance Test
Date and time of acceptance test: 6a...411 I 1.31 Q/
Installing contractor representative: //OMin L f G ✓&r tcet,tv 1
Testing contractor representative: PcIlitin j (V 1;1e/ /1000
Property representative: 4I-(\ we lL{ ry 1)E(1
ART representative:
copyright fl 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.
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