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Report B SIm Iex FIRE ACKNOWLEDGEMENT TEST/INSTALLATION , $� Awe ^ a I/ Gardner, MA 01441 -0001 U.S.A. Re fba-T- PAGE OF , L�1'v 1 31 - 5. t CALL ft SEO. 1 I I 1 1 1 CH SERVICE AT CUSTOMER NUMBER SRE AND PROJECT NO. TR ARRIV DATE (((��R MP. D T N BILL SVC.CODE MIN TRACT 1 B 'I 1 1 1 1 1 1 1 1 1 1 1,1 1 1 1 1 I CI Fl 1 1 I I DAT i f - - CUSTOMER P.O. AND /OR CUSTOMER CONTACT NAME (PRINT) . NAMF� `yA` ' `� �'�! * ;� i. � 1 � ,/�V �� 1� I � I �° ' 1 1 1 J 1 1 1 1 J 1 1 1 1 1 1 1 1 1 I 1 1 1 I • ADDRESS OR. ..g 1 f) /�1j �� .� ', �//� - SERVICE CODE LBR • REG. TRAY - REG. LBR - OT TRAV • OT MILES 5 � 1 J S U.J `" 1 Z ‘ l. T -% • I I 1 I I I I I 1 I 1 I ADOR yy�' WARRANTY CODE LBR - REG. TRAV • REG. LBR - OT TRAV - OT ARRIVAL 1 1 1 1 I 1 1 1 1 1 1 • 1 CITY 1is A �A STA� ( 1722 ,- : TLP CODE LBR - REG. TRAV - REG. LBR - OT TRAV - OT DEPARTURE • CONTROL PANEL M I RER ,�� MODEL NO�� j� E '' 0 WIRING DIAG. NO. SEQUENCE NO. S / ^ Y / O U THRU TYPE OF SIGNALING POWER CIR. BRKR LOCATION NO LOCKED CIR. BRKR EDICATED CIR. 1�SENERAL ALARM ❑ SELECTIVE SIGNALS ❑ CODED ❑ PRE - SIGNAL SOURCE . C1. t i-4 A'g' l9I ki. ❑ N Y ❑ N BATTERIES VOLTAGE WITH CHARGER ❑ ORM aVOLTS TROUBLE RESPONSE TO: ZONE TROUBLE SIGNAL TROUBLE AC /OP POWER LOSS EARTH GROUND ❑ NOTE p VOLT WITHOUT CHARGER ❑ ❑ N/A _% CHARGED CONDITIONS NORM ❑ NOTE # I . • 'M ❑ NO 5 I , NORM ❑ NOTE N "DORM 12 NOTE S CUSTOMER OPERATING INSTRUCTIONS PROVIDED TO: STR TR 1 SIGNATU TEL NO. ( ) ' r L 1 I + , 1547' 'SS CUSTOMER SIGNATURE FIRE ALARM UCENSE NO. - STATE CERTIFICATIO ` N SEE NOTATION NO, THE SIMPLEX- SUPPLIED EQUIPMENT FOR THIS SYSTEM WAS TESTED AND SIG ALS SOUNDED PER CUSTOMER REQUEST FOUND OPERATIONAL THE WARRANTY BEGINS ON MONTH DAY YR. L? • N CUST. INIT. I AUXILIARY FUNCTIONS - GR. SERIAL DOOR DOOR RELEASE DEVICES, INCLUDING CLOSERS AND LATCHES ANNUNCIATOR e � HOLDERS 0 NORM 0 QTY. ❑ NOTE +/ ❑ N/A MODEL,i '� r , q WIRING DIAGRAM ELEVATOR RECALL TO PRIMARY FLOOR ( (� , J ) FIRE RECALL ❑ NORM ❑ NOTE it ❑ N/A V T ❑ INCAND. ❑ GRAPH tV IC ❑ CRT NO. OF ZONES UNUSED PTS. RECALL TO ALTERNATE FLOOR ELEVATORS RESTART TYPE ❑ LED ❑ DROPA( 6 1 FROM FIRE SVC. �,,, 0 0 A' ❑ WA SHUTDOWN AUTOMATICALLY ❑ Y ❑ N AUX ❑ LAMP TEST �gelEMOTE RESET ADDITIONAL NOTES: HVAC AIR HANDLER SHUTDOWN AIRHANDLER(S) FUNCTIONS ❑ DRILL SW YTREMOTE ACK SHUTDOWN ❑ NORM ❑ NOTES ❑ QTY. SHUTDOWN AUTOMATCALLV ❑ Y ❑ N SPECIAL LIST ANY UNIQUE FUNCTIONS CONSIDERATIONS - TO BE AWARE OF BEFORE TESTING CITY CITY RESPONSE TO ALARM OFFICIAL CONTACTED 1. CONNECTION OR L MORM ❑ NOTE M CENTRAL MONITORING CITY RESPONSE TO TROUBLE TIME OF DAY 2. STATION AORM ❑ NOTE 5 _ OUT OF SERVICE 1 IN SERVICE LOCAL FIRE DEPT ENTRAL STATION \ FD. I •H • HONE • fTAL S- N 39 3 MPX /TPR CHECKLIST PERIPHERAL /PARTS USED THE NUMBER OF PERIPHERAL DEVICES TESTED ARE: MODEL NO. THE FOLLOWING TRANSPONDERS FAILED THE TEST ITEM PRODUCT I.D. QTY. INV.LOC. /SEO. NC USG. UNIT PRICE TOTAL NO. No, I okay OF DEVICES Tested X See below NO. OF XPNDRS TESTED LOCATION NOTE S 1 STATIONS 0 1 1 1 1 1 1 1 1 1 I I I I 11 •1 I I I 1 I � POWER SUPPLY VOLTAGE NOTE 0 LOCATION NOTE A 2 I ` `u, 111 I I I I Slp� DEIECIONS r `�� ❑ NORM 1 1 1 1 1 1 1 1 1 1 CHARGER VOLTAGENOTE 5 LOCATION NOTE 9 1 3 ANIAMOAIORS ❑ NORM 1 1 1 1 1 1 1 1 1 1 r 1 .-W I l I I 11 GROUND FAULT NOTES LOCATION NOTE d DUCT DLIH.HJH a.. Z 4 0 0 I 1 1 1 1 1 1 1 I 1 1 I I 1 1 1 I I � Z 4Z BATTERIES VOLTAGE NOTE 8 LOCATION NOTE i 5 / IC (5 �- ❑ NORM I yl �F I I I 1 1 I I I I I I POINTS TESTED NOTES LOCATION NOTES CHIMES B J ❑ NORM 1 1Y1 1 1 1 1 1 1 1 1 I I 1 1 1 1 1 1 SPflPDDER SYST ._ _ OTHER NOTES LOCATION NOTE S 7 NURSE CALL 1 I I I l l l l l I I I 1 1 1 I l I 1 I _ TYPE PROGRAM PRINTERS NOTES CRTS NOTES OTHER NOTED 8 0 0 ❑Y 0 ' VOICE MESSAGE _ FAILURES AND SYSTEM DEVIATIONS FROM NFPA STANDARDS: � 4 None I As Follows (describe fully) RELATED TR RELATED CALL (/ 1 1 I 1 1 I I 1 1 , • PROBLEM CODE CORRECTIVE ACTION CLOSE DATE SERV. COMPL I RSN 1 1 1 I - 1 lF DETAILED TESTING IS REQUIRED - USE CONTINUATION SHEET AOV-0352 M - 552 - 9 • AUTHORITY HAVING JURISDICTION • - • g;simplex FIRE ALARM TEST /INSTALLATION .. 8 utp0 - 00Lf a q 1 'Gardner, MA 01441 -0001 U.S.A. 'ACKNOWLEDGEMENT ONTINUATION``SHEET- INC. p. 2� A i ` r " MK -0 BOOK # CALL # • 11i P A. f - IM. ---- -4 PG OF PERIPHERAL FUNCTION TEST DEVICE DEVICE LOCATION T R S NOTE ANNUN. ZONE ALARM ZONE DEVICE DEVICE LOCATION . , T S N ANNUN. ZONE ALARM ZONE TYPE OU N NO. OR OR TYPE $ NO. OR OR S OTE TBEPHONE SIGNAL B E S I T TETE PHONE SIB a LE 1 T ZONE ZONE 1 \* .T 1-1 Ti k ✓bSL �X �.1 1 -25 t ,r ? . -. t - — ( -3 ``Z`P ,�cti M+lea /-ZCs }"re `• -4 P5i> i• a Ares / -Z7 1 It'or T.: ..6-'. t '.: 4 1 i '.. 2 1-zcf 61 ( -7: ; - ; 1 -32 4 / !, ► "� I ,:z' 1 .,s I - E. 4— U i 33 i—ci I 4 �a.1\ 1-3i 9 � I P ND ! ls+ t lec inn . l -'5 D I`m %Pl e: •n ` I -I k (Kg I �} ale.) £qvl i ! -3(o l'.'45 p t `�-�` ( -12 V5 1m deal &q'■? 11 ( -37 .0. , , I � 1-13 (S }- E, -W 1 4 1-55 �' M1 ► ! /3 M 1 �-014).V I, 1 -37 r i I-I' -1 1 b 5E DTer� Aieat, I l `l; . i k ;' 1 -15 f! 5, 1 /-411 f>1 -T 14 HI i- � - / -yz ‘- r 5 2 H9 ,- cr ∎ I -L/3 1Vr fv-"124 Q 1-2 i V I p8 ( PSD = otoeric Smk Det PSF = Man Pull = = h" 1 J 1 - ISD = Ion lect Smk Det CPS =Coded ual Pull Station H B = Hom Bell OnOnly ty TS WF =Water Tamper Flow Switc Sw I' Ebb �bb,` N —�^ PDD = Photo. Duct Smk Det RR = C = mty H = a f I ` IDD = Ion'Duct Smk Det HT Rate = Fixed of Temp Rise Heat Ht Det Det S Chi = Spkr e OntOny FP D = Fre Door, Phon Holder , _ Z3 DHS = = Door Hldr & Smk Det MD = = Flame Mercoid Det Heat Det AN = Audio Visual PJ = Phone Jack 1 �� s �a\` ' 550 Sgl Station Smk Det FD V = Visual Onty NCS = Nurse Call Sta. MWC a —� BD =Beam Det. — = — = — _ FAILURES AND SYSTEM DEVIATIONS FROM NFPA STAIIIDM DS: • None II As Follows (describe fully) 1 ■ t • 1 • . • AUTHORITY HAVING JURISDICTION ADV -0352 1 -93 rr -. _ :Simplex FIRE ALARM TEST /INSTALLAEIQN 61. out a Li Gardner, MA 01441 -0001 U.S.A. ACKNOWLEDGEMENT G,ONTINUATION S 1t�E ET R 6 rt.,r, r- 0 , NAME / BOOK # CALL # b.' \V` c kilt- t'h- -I \ --rC.e PG 3 O PERIPHERAL FUNCTION TEST DEVICE DEVICE LOCATION T S NOTE ANNUM. ZONE ALARM ZONE DEVICE DEVICE LOCATION TB S NOTE ANNUM. ZONE ALARM ZONE TYPE N NO. OR OR TYPE NO. OR OR S TELEPHONE SIGNAL B S TELEPHONE SIGNAL B L E I T ZONE ZONE E I T ZONE ZONE P5v 2.6(1.&11,0 ► ' 4 - 1 S' LObb' / / - 7d "si t ' / I -yfg Zn aP�ea .0 / -7! 117 F . I -4e / JAR \i„, ti t+P 5 L 1 cA << / I -c N/ zr,d E . W.. 1 -75 '?5D 2 LAY y:Ac 1-51 MPS z nd . E . -;dear I .-71c 2 A 5 tZ e • ea - A - • A -Z P'�v • . 6 :�t • a 1- • /� I-53 1S 1-7? .. • . t-9 1 ► �' ' t . I-go N/ ' \/ W 1-'62._ ► � 1 III Z-1 I,t)orr€ 5 15 PDD X1-10 t /-8( 2,,� ��5 b 1-s9 ADD A Div 2, pi 1 ?7 Zed, N all / 1 1-61) Zv ReCeion . I- (91 Zhu Eb.1�i r 4 Ha. Z. E lexr g, ► 1 -� s • ' 1 ■ (1 PSD = Photoelectric Smk Det PS = Manual Pull Station 8 = BeU Only TS = Tamper Switch " Z G 'r �-{\ , /- ISD = Ionization Smk Det CPS = Coded Pull Station H = Horn Only WF = Water Flow Sw 1 {.►, ?S ZA \ Lobby y _/ y� PDD = Photo. Duct Smk Det RR = Rate of Rise Ht Det C = Chime Only DH = Door Holder _\ Q` � �♦ ' ( IDD = Ion. Duct Smk Det HT = Fixed Temp Heat Det S = Spkr Only FP = Fire Phone �' D Z v\ '(�\ �b y / I - �� SSD = Sg Station & Smk Det l MFDD = M Visual Fla ne Deteat Det AN = Visual Only NCS = Nurse Call ta. b Lobb / -•/ BD = Beam Det. — — _ — _ FAILURES AND SYSTEM DEVIATIONS FROM NFPA STAIIDAFIDS: • None • As Follows (describe fully) 1 • • • AUTHORITY- HAVING JURISDICTION • ADV-0352 1-93. NFPA RECORD OF COM • ETION Name of Protected Property: i . a . t 11 Address: 2 31,1 ' n I � lif 2Z. Rep. of Protected Prop. (name /phone): Authority Having Jurisdiction: Address /Phone Number: 1. Type(s) of System or Service 11 NFPA 72, Chapter 3 - Local If alarm is transmitted to location(s) off premises, list where received: F NFPA 72, Chapter 3 - Emergency Voice /Alarm Service Quantity of voice /alarm channels: Single: Multiple: Quantity of speakers installed: Quantity of speaker zones: Quantity of telephones or telephone jacks included in system: n NFPA 72, Chapter 4 - Auxiliary Indicate type of connection: - Local energy: Shunt: Parallel telephone: Location and telephone number for receipt of signals: I NFPA 72, Chapter 4 - Remote Station Alarm: Supervisory: n NFPA 72, Chapter 4 - Proprietary If alarms are retransmitted to public fire service communications center or others, indicate location and telephone number of the organization receiving alarm: Indicate how alarm is retransmitted: m NFPA 72, Chapter 4 - Central Station The Prime Contractor: ��11 Central Station Location: 5 *e e_ G ri At , � fid►CiV1 r1ct .0 7 Means of transmission of signals from the protected premises to the central station: McCulloh Multiplex One -Way Radio Digital Alarm Communicator Two -Way Radio Others Means of transmission of alarms to the public fire service communications center: (a) (b) System Location: Organization me /Phone Representative Name /Phone Installer f,i).Ar ,l E 14,0A-6(.. Supplier be M P � lr rv\v L.41 Service Organization S P I eSCGfiANLA` Location of Record (As- Built) Drawings: P \v%.i_\ R M . Location of Owners Manuals: a.r�Q-1 K M . Location of Test Reports: � t$J -1 t, i• A contract, dated , for test and inspection in accordance with NFPA standard(s) No(s). dated , is in effect. 2. Record of System Installation (Fill out after installation is complete and wiring checked for opens, shorts, ground faults, and improper branching, but prior to conducting operational acceptance tests.) This system has be n install d i accord a with the NFPA standards s shown below, was inspected by ! • t G� on, ' ) 4 .o1 includes the devices shown below, and has been in service since (. - 1 '0 ` . V NFPA 72, Chapters 6 © Q 6 ©0 (circle all that apply) NFPA 70, National Electrical Code, Article 760 Manufacturer's instructions Other (sp -ci ): /_ Signed: - ✓ . ii %% _ Date: r!�ir itel • Organization: ft-1C...1 AHJ - White; Owner - Canary; Branch - Pink; Site Copy - Goldenrod Adv- 1142 -2 Part 1 of 3 S. System Power Supplies /n�`/ (a) Primary (Main): Nominal Voltage: `'V `r Current Rating: 20A- Overcurrent Protection: Type: Current Rating: Location: (b) Secondary (Standby): ` •A Storage Battery: Amp -Hour Rating ` ,^ Calculated capacity to drive system, in hours: 24 X 60 Engine- driven generator dedicated to fire alarm system: Location of fuel storage: (c) Emergency or Standby System used as backup to Primary Power Supply, instead of using a Secondary Power Supply: - Emergency System described in NFPA 70, Article 700 - Legally Required Standby System described in NFPA 70, Article 701 - Optional Standby System described in NFPA 70, Article 702, which also meets the performance requirements of Article 700 or 701 9. System Software (a) Operating System Software Revision Level(s): " 2-•01 (b) Application Software Revision Level(s): •(7 (c) Revision Completed by: 0. . • A • •12___A"_ /_ _ . vk.1 J _ _ . - la ♦ (name) (firm) 10. Comments: (signed) for Central Station or Alarm Service Company (title) (date) Frequency of routine tests and inspections, if other than in accordance with the referenced NFPA standards(s): System deviations from the referenced NFPA standard(s) are: 1 1 11 4 :.' • • - (signed) for Central Station o Alarm Service Company (title) (date) Upon completion of the system(s) satisfactory test(s) witnessed (if required by the authority having jurisdiction): 4110 • ...ter.• /�L signed) rep esentative of the authority having jurisdiction t itle) (date) AHJ - White; Owner - Canary; Branch - Pink; Site Copy - Goldenrod Adv- 1142 -2 Part 3 of 3 3. Record of System Operation b � � � ' ^ ` 1 � � �q I All operational features and functions of this system were tested by C on, (S/ and fo d to be operating properly in accoTrrdd�anc with the requirements of: �O NFPA 72, ChaptersC(circle all that apply) NFPA 70, National Electrical Code, Article 760 _be.— Manufacturer's Instructions Other (specify): Signed: Date: Organization: 4. Alarm- Initiating Devices and Circuits (use blanks to indicate quantity of devices) MANUAL (a) AS Manual Stations Non coded, Activating Transmitters Coded (b) Combination Manual Fire Alarm and Guard's Tour Coded Stations AUTOMATIC Coverlaye: Complete: Partial: (a) V 1 --• Smoke Detectors Ion Photo (b) Duct Detectors Ion Photo (c) Heat Detectors FT RR FT /RR RC (d) j Sprinkler Waterflow Switches: Transmitters Non coded, Activating Coded (e) Other (list): 5. Supervisory Signal- Initiating Devices and Circuits (use blanks to indicate quantity of devices) GUARD'S TOUR (a) — Coded Stations (b) Non coded Stations, Activating Transmitters (c) _ Compulsory Guard Tour System Comprised of Transmitter Stations and Intermediate Stations NOTE: Combination devices recorded under 4(b) and 5(a). SPRINKLER SYSTEM (a) _' . Coded Valve Supervisory Signaling Attachments Valve Supervisory Switches, Activating Transmitters (b) Building Temperature Points (c) — Site Water Temperature Points (d) — Site Water Supply Level Points Electric Fire Pump: (e) Fire Pump Power (f) Fire Pump Running g) Phase Reversal Engine- Driven Fire Pump: (h) Selector in Auto Position (i) Engine or Control Panel Trouble (j) Fire Pump Running Engine- Driven Generator: (k) Selector in Auto Position (I) Control Panel Trouble (m) Transfer Switches (n) Engine Running Other Supervisory Function(s) (specify): 6. Alarm Notification Appliances and Circuits Quantity of indicating appliance circuits connected to the system: Types and quantities of alarm indicating appliances installed: (a) Bells Inch (b) Speakers (c) Horns (d) Chimes (e) Other: _ (f) 51 Visual Signals Type: sue / with audible `(7, w/o audible 5 (g) Local Annunciator 7. Signaling Line Circuits Quantity and Style (see NFPA 72, Table 3 -6) of signaling line circuits connected to system: Quantity: Style: AHJ - White; Owner - Canary; Branch - Pink; Site Copy - Goldenrod Adv- 1142 -2 Part 2 of 3