Report Jul. 16. 2010 11:02AM No, 9227 P. 1/5
FPS Zo, -o - c-Do oS
FIRE ALARM SYSTEM RECORD OF COMPLETION
To be completed by the system installation contractor at the time of system acceptance and approval,
1. Protected Property Information
Name of property: Pacific Parkway Center
Address: 12909 SW 68 Parkway, Suite 450
Description of property: ACE American Insurance Company
Occupancy type:
Name of property representative: Dennis Pagni
Address: 15350 SW Sequoia Parkway #300
Phone: 503 -624 -6300 Fax: E -mail:
Authority having jurisdiction over this property: City or Tigard
Phone: 503- 639 -4171 Fax: E -mail:
2. Fire Alarm System Installation, Service, and Testing Information
Installation contractor for this equipment: Stanley Convergent Security Solutions
Address: 15495 SW Sequoia Pkwy Ste, 100, Portland, OR 97224
Phone: 5039683300 Fax: 5039683397 E -mail:
Service organization for this equipment: Stanley Convergent Security Solutions
Address: 15495 SW Sequoia Pkwy Ste. 100, Portland, OR 97224
Phone: 5039683300 Fax: 5039683397 E-mail:
Location of as -built drawings: Location of Historical Test Reports:
Location of system operation and maintenance manuals:
A contract for test and inspection in accordance with NFPA standards is in effect as of
Contracted testing company: Stanley Convergent Security Solutions
Address: 15495 SW Sequoia Pkwy Ste. 100, Portland, OR 97224
Phone: 5039683300 Fax: 5039683397 E - mail:
Contract expires: Contract number: Frequency of routine inspections:
3. Type of Fire Alarm System or Service
NFPA 72 Chapter Reference of System Type:
Name of organization receiving alarm signals with phone numbers (if applicable):
Alarm: Stanley CSS Phone: 8778990001
supervisory: Stanley CSS Phone: 8778990001
Trouble: Stanley CSS Phone: 8778990001
Entity to which alarms are retransmitted: Phone:
Method of retransmission of alarms to that organization or location:
NFPA 72, Fig, 4,5,2,1 (p, 1 of 5)
Copyright 02000 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,
Jul. 16. 2010 11:02AM No. 9227 P. 2/5
If Chapter 8, note the means of transmission from the protected premises to the central station;
❑ Digital alarm communicator ❑ McCulloh ❑ Multiplex ❑ 2 - way radio ❑ 1 - way radio ❑ N/A
if Chapter 9, note the type of connection: ❑ Local energy ❑ Shunt ❑ N/A
3.1 System Software
Operating system (executive) software revision level:
Site - specific software revision date: Revision completed by:
4. Signaling Line Circuits
Characteristics of signaling line circuits connected to this system (see NFPA 72 Table 6.6.1):
Quantity: Style: Class:
5. Alarm Initiating Devices and Circuits
Characteristics of initiating device circuits connected to this system (see NFPA 72 Table 6.5):
Quantity: Style: Class:
5.1 Manual Initiating Devices
5.1.1 Manual Pull Stations Number of manual pull stations:
Type of devices: ❑ Addressable ❑ Conventional ❑ Coded 0 Transmitter ❑ N/A
5.2 Automatic Initiating Devices
5,2.1 Area Smoke Detectors Number of smoke detectors:
Type of coverage: ❑ Complete area ❑ Partial area ❑ Nonrequired partial area ❑ N/A
Type of devices: ❑ Addressable ❑ Conventional ❑ Coded ❑ Transmitter ❑ N/A
Type of smoke detector sensing technology: ❑ Ionization ❑ Photoelectric
5.2.2 Duct Smoke Detectors Number of duct smoke detectors:
Type of coverage: . .
Type of devices; ❑ Addressable ❑ Conventional ❑ Coded 0 Transmitter ❑ N/A
Type of smoke detector sensing technology: ❑ Ionization ❑ Photoelectric
5.2.3 Heat Detectors Number of heat detectors:
Type of coverage: ❑ Complete area ❑ Partial area ❑ Nonrequired partial area ❑ N/A
Type of devices: ❑ Addressable ❑ Conventional ❑ Coded ❑ Transmitter ❑ N/A
5.2.4 Sprinkler Waterflow Detectors Number of waterflow detectors:
Type of devices: ❑ Addressable ❑ Conventional ❑ Coded ❑ Transmitter ❑ N/A
5.2.5 Alarm Verification Number of devices subject to alarm verification:
Alarm verification on this system is: ❑ Enabled ❑ Disabled ❑ Set for seconds
6. Supervisory Signal - Initiating Devices and Circuits
6.1 Sprinkler System Number of valve supervisory switches:
Type of devices: ❑ Addressable ❑ Conventional ❑ Coded ❑ Transmitter ❑ N/A
NFPA 72, Fig. 4.5.2.1 (p. 2 of 6)
Copyright to 2009 National Fire Protection Association. This form may be copied for lndlActual use other than for resale, It may not be copied for commercial sale or distribution.
Jul. 16. 2010 11:02AM No. 9227 P. 3/5
6.2 Fire Pump
Type of fire pump: ❑ Electric ❑ Diesel
Type of fire pump supervisory devices: ❑ Addressable ❑ Conventional ❑ Coded ❑ Transmitter ❑ N/A
Fire Pump Functions Supervised
El Fire pump power El Fire pump running ❑ Fire pump phase reversal ❑ Selector switch not in auto
❑ Engine or control panel trouble ❑ Low fuel
Other:
•
6.3 Engine - Driven Generator •
Type of generator supervisory devices: El Addressable ❑ Conventional ❑ Coded [J Transmitter ❑ N/A
❑ Engine or control panel trouble ❑ Generator running ❑ Selector switch not in auto ❑ Low fuel
Other:
7. Annunciators
7.1 Annunciator 1 ❑ Local ❑ Remote
Type: ❑ Addressable ❑ Directory ❑ Graphic ❑ N/A Location:
1.2 Annunciator 2 ❑ Local ❑ Remote
Type: ❑ Addressable ❑ Directory ❑ Graphic ❑ N/A Location:
7.3 Annunciator 3 ❑ Local ❑ Remote
Type: O Addressable ❑ Directory ❑ Graphic C] N/A Location:
8. Alarm Notification Devices and Circuits
8.1 Emergency Voice Alarm Service
Number of single voice alarm channels: Number of multiple voice alarm channels:
Number of speakers: Number of speaker zones:
8.2 Telephone Jacks
Number of telephone jacks installed: Number of telephone handsets stored on site:
Type of telephone system installed: ❑ Electrically powered ❑ Sound powered ❑ N/A
8.3 Nonvoice Audible System
Characteristics of notification device circuits connected to this system (see NFPA 72 Table 6.5):
Quantity: 74410 Style: Class: ,
8.4 Types and Quantities of Nonvoice Notification Appliances Installed G
Bells: With visual device: Horns: / /s/t With visual device: /'f
Chimes: With visual device: Bells: With visual device:
Visual devices without audible devices: Other (describe):
•
NFPA 72, Fig. 4.5.2.1 (p. 3 of 5)
Copyright 02009 National Fire Protection Association. This form may be copied for individual use other than for resale. It may not be copied for commescial sale or d iebtbution.
Jul. 16. 2010 11:02AM No. 9227 P. 4/5
9. Emergency Control Functions Activated
❑ Hold -open door releasing devices 0 Smoke management or smoke control
❑ Door unlocldng [] Elevator recall ❑ Other
10. System Power Supply
10.1 Primary Power
Nominal voltage: Amps:
Overcurrent protection: Type: Amps:
Location (of primary supply panelboard):
Disconnecting means location:
10.2 Secondary Power
Location: Type: Nominal voltage: Current rating:
Number of standby batteries: Amp hour rating:
Location of emergency generator:
Location of fuel storage:
Calculated capacity of secondary power to drive the system
In standby mode: In alarm mode:
11.Record of System Installation
Fill out after all installation is complete and wiring has been checked for opens, shorts, ground faults, and improper
branching. but before conducting operational acceptance tests.
The system has been installed in accordance with the following NFPA standards; (Note any or all that apply.)
NFPA 72 NFPA 7e, Article 760
❑ Manufacturer's published instructions ❑ Other (please specify): .
System deviations fr refere ced NFPA standards:
Signed: • Printed name: Ken Craft Date: 7/13/2010
Organization: Stanley CSS Title: Fiala Service Technician Phone; 503.868 -3300
12. Record of System Operation
All operational features and functions of this system were tested by or in the presence of the signer shown below, on the date
shown below, and were found to be operating properly in accordance with the requirements of:
❑ NFPA 72 ❑ NFPA 70` Article 760
❑ Manufacturer's published instructions ❑ Other (please specify):
❑ Documental ' accordance with Inspection and Testing Form (Figure 10.6.2.3 of NFPA 72 is attached
Signed: Printed name: Ken Craft Date: 7113/2010
Organization: Stanley Title: .3355
Field Service Technician Phone: 503. 968
NFPA 72, Fig. 4,5.2,1 (p. 4 of 5)
Copyright 0 2008 National Fire Protection association. This form may be copied for individual Lite other than for resale. 11 may not be copied for commercial sale or dstribution.
Jul. 16. 2010 11:02AM No. 9227 P. 5/5
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13.Certlflcations and Approvals
13.1 System Installation Contractor
•
This system as speci d herein as been in tailed and tested according to all NFPA standards cited herein.
Signed: - Printed name: Ken Craft Date: 7/13/2010
Organization: Stanley CSS Title: Flels Service Technician Phone: 503- 968 -3300
13.2 System Service Contractor
This system as s etfied hereja has b n installed and tested according to all NFPA standards cited herein.
Signed; � g . Prin name:. Ken Craft Date: 7/13/2010
Organization; Stanley CSS Title: Field Service Technician Phone: 503- 968 -3300
13.3 Central Station
yip This s M'I' as spec' ercin will b• ored according to all NFPA standards cited herein.
S i g n . * / ' Printed name: Gary Tauscher Date: 7/13/2010
Organization: Manley CSS Title: Operations Manager Phone: 503 -968 -3355
13.4 Property Representative
I accept this sy as h ng bee nstalled and tested to its specifications and all NFPA standards cited hereiin.
Signed: Printed name; �, y rj,rl � Date : /e//�
Organizati — 7'7� Title: d w rift',, 441 u,,./ -1 .. Phone: 4 Jt -
13.5 Authority Having Jurisdiction
I have witnessed a satisfactory acceptance test of this system and find it to be installed and operating properly in accordance
with its approved plans and specifications, its approved sequence of operations, and with all NFPA standards cited herein.
Signed: Printed name: Date:
. ._ . . .. ._
Organization: Title: Phone:
NFPA 72, Fig. 4.5,2,1 {p. 5 of 5)
Copyright ® 2009 National Firo Pratemon Association. This form may be copied for Individual use other than for resale. It may not be copied for commercial sale or distribution.