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FPS zot0 - cDolZf Fire Alarm System Record of Completion Name of property protected: Triangle Point Building Address: 13333 SW 68 Pkway, Tigard, OR Representative of protected property (name /phone): Authority having jurisdiction: Tigard, OR • Address /telephone number: Organization name / phone Representative name / phone Installer: Rosendin Electric Supplier: Johnson Controls Service Organization: Johnson Controls, Inc. Location of record (as- built) drawings: FACP Room Location of operation and maintenance manuals: Location of test reports: FACP Room A contract for test and inspection in accordance with NFPA standard(s) Contract No(s): Effective date: Expiration date: System Software (a) Operating system (executive software revision level(s) : (b) Site - specific software revision date: (c) Revision completed by: Steven Beachner Johnson Controls Inc (name) (firm) 1. Type(s) of System or Service NFPA 72, Chapter 6 — Local If alarm is transmitted to location(s) off premises, list where received: XX NFPA 72, Chapter 8 — Central Station Prime contractor: Alarm Central Station Central station location: Beaverton, OR Means of transmission of signals from the protected premises to the central station: Digital alarm communicator Two -way radio Others Means of transmission of alarms to the public fire service communications center: (a) PUBLIC TELEPHONE (b) System location: 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 been installed in accordance with NFPA standards as shown below, was inspected by Steven Beachner on 11/5/10 , includes the devices shown in 5 and 6, and has been in service since 11/5/10 X NFPA 72, Chapters 1 2 3 4 5 6 7 8 9 10 11 (circle all that apply) X NFPA 70, National Electrical Code, Article 760 X Manufacturer's instructions Other (specify): Signed: Date: 11/5/10 Organization: o nson Controls 3. Record of System Operation Fire Alarm System Record of Completion (based on NFPA 72 - 2002) NFPA 72, 1 of 3 Triangle Building NFPA -72 11-5-10 1 si oio 9:09:00 AM R.L. Suckow Fs Reprinted with permission from NFPA 72 -2002, National Fire Alarm Code ®, Copyright ® 2002, National Fire Protection Association, Quincy, MA, 02269 a Documentation in accordance with Inspection Testing Form, Figure 10.6.2.3, is attached N/A • All operational features and functions of this system were tested by Steven Beachner date 11/5/10 And found to be operating properly in accordance with the requirements of: X NFPA 72, Chapters 1 2 3 4 5 6 7 8 9 10 11 (circle all that apply) X NFPA 70, National Electrical Code, Article 760 X Manufacturer's instructions Other (sp-cify): Signed: >> Date: 11/5/10 „iv ...- Organization: Johnson Controls 4. Signaling Line Circuits Quantity and class of signaling line circuits connected to system (see NFPA 72, Table 6.6.1): Quantity: 8 Style: 4 Class: B 5. Alarm Initiating Devices and Circuits Quantity and class of initiating device circuits (see NFPA 72, Table 6.5): Quantity: 2 Style: C Class: B MANUAL (a) Manual stations: Non -coded Transmitters Coded Addressable (b) Combination manual fire alarm and guard's tour coded stations AUTOMATIC Coverage: Complete Partial Selective x Nonrequired (a) Smoke detectors Ion Photo Addressable (b) Duct detectors Ion Photo 9 Addressable (c) Heat detectors FT RR FT /RR RC Addressable (d) Sprinkler waterflow indicators: Transmitters Noncoded Coded Addressable 6 (e) The alarm verification feature is disabled XX or enabled , changed from seconds to seconds. (f) Other (list): None Added, Tested 11 exsisting photo detectors and 4 exsisting manual pullstations relocated down to drop ceiling. 6. Supervisory Signal Initiating Devices and Circuits (use blanks to indicate quantity of devices) SPRINKLER SYSTEM Check if provided (a) 8 Valve supervisory switches (b) Building temperature points (c) Site water temperature points (d) Site water supply level points 7. Annunciator(s) Number: Non Added Type: Location: 8. Alarm Notification Appliances and Circuits NFPA 72, Chapter 6 — Emergency Voice/Alarm Service Quantity of voice/alarm channels: Single: Multiple: Quantity of speakers installed: Quantity of speaker zones: Types and quantities of notification appliance circuits connected to system (see NFPA 72, Table 6.7): Quantity: Style: Y Class: B (a) Bells With Visible (b) Speakers With Visible (c) Horns With Visible 3 (d) Chimes With Visible (e) Others With Visible (f) Visible appliances without audible 9. System Power Supplies (a) Fire Alarm Control Panel: Nominal voltage: 24VDC Current rating: 5 Fire Alarm System Record of Completion (based on NFPA 72 - 2002) NFPA 72, 2 of 3 Triangle Building NFPA -72 11-5-10 11/5/2010 9:09:00 AM R.L. Suckow Reprinted with permission from NFPA 72 -2002, National Fire Alarm Code ®, Copyright ® 2002, National Are Protection Association, Quincy, MA, 02269 Overcurrent protection: Type: Current rating: Location (b) Secondary (standby: Storage battery: MAIN PANEL Amp -hour rating: Exsisting System Storage battery: Amp -hour rating: Storage battery: Amp -hour rating: Calculated capacity to drive system, in hours: 24+ 10. Comments Frequency of routine tests and inspections, if other than in accordance with the referenced NFPA standard(s): System deviations from the referenced NFPA standard(s) are: Replaced 3 strobes with horn /strobes on second floor. Fo4Ig -/% {Al // -6 o signed) for installatio actor /supplier (title) (date) sYsFA -cs r� I ,S /a (' ned) f rm service company (title) (d e) (sign= • central station _ (title) (date) U.. j • mpletion of the syst - • s) satisfactory test(s) witnessed (if required by the authority having jurisdiction): rgned) rep tatii authority having jurisdiction (title) (date) Fire Alarm System Record of Completion (based on NFPA 72 - 2002) NFPA 72, 3 of 3 Triangle Building NFPA -72 11-5-10 11/5/2010 9:09:00 AM R.L. Suckow Reprinted with permission from NFPA 72 -2002, National Fire Alarm Code ®, Copyright ® 2002, National Fire Protection Association, Quincy, MA, 02269 fd 1 EVENT HISTORY # Date Time Event 1 11/05/2010 07:28 AM System Silenced 2 11/05/2010 07:28 AM Silence Request 3 11/05/2010 07:28 AM System Unsilenced 4 11/05/2010 07:28 AM Detection Alarm Restore. Zone 1 5 11/05/2010 07:28 AM Manual Pull Alarm Restore. Zone 1 6 11/05/2010 07:28 AM Water Flow Alarm Restore. Zone 1 7 11/05/2010 07:28 AM System Reset 8 11/05/2010 07:28 AM _ Photo Det Alrm Rst Zone 001 [M33:P113] 9 11/05/2010 07:28 AM ManPull Alrm Restore Zone 001 [M33:P109] 10 11/05/2010 I 07:28 AM Photo Det Alrm Rst Zone 001 [M33:P108] 11 11/05/2010 07:28 AM Photo Det Alrm Rst Zone 001 [M33:P089] 12 11/05/2010 07:28 AM Photo Det Alrm Rst Zone 001 [M33:PO47] 13 11/05/2010 07:28 AM Det Switch Alarm Rst Zone 001 [M33:P010] 14 11/05/2010 07:28 AM Det Switch Alarm Rst Zone 001 [M33:P009] 15 11/05/2010 07 :28 AM WatFlow Alrm Restore Zone 001 [M33:P008] 16 11/05/2010 07:28 AM User Login Profile 1 17 11/05/2010 07:28 AM User Exited 18 11/05/2010 07:25 AM Silence Request 19 11/05/2010 07:25 AM Supv/Tamper Restore Zone 001 [M33:P002] 20 11/05/2010 07:25 AM Supervisory Off /Norm Zone 001 [MO2:P110] 21 11/05/2010 07:25 AM Supervisory Off /Norm Zone 001 [MO2:P109] 22 11/05/2010 07:25 AM Supv/Tamper Off /Norm Zone 001 [M33:P002] 23 11/05/2010 07:25 AM Supervisory Restore Zone 001 [MO2:P110] 24 11/05/2010 07:25 AM Supervisory Restore Zone 001 [MO2:P109] 25 11/05/2010 07:25 AM Supv/Tamper Restore Zone 001 [M33:P002] 26 11/05/2010 07:25 AM Supervisory Off /Norm Zone 001 [MO2:P110] 27 11/05/2010 07:25 AM Supervisory Off /Norm Zone 001 [MO2:P109] 28 11/05/2010 07:25 AM Silence Request 29 11/05/2010 07:25 AM Supervisory Restore Zone 001 [MO2:P110] 30 11/05/2010 07:25 AM Supv/Tamper Off /Norm Zone 001 [M33:P002] 31 11/05/2010 07:25 AM Silence Request 32 11/05/2010 07:25 AM Supervisory Off/Norm Zone 001 [MO2:P110] 33 11/05/2010 07:23 AM Supervisory Restore Zone 001 [MO2:P110] 34 11/05/2010 07:23 AM Supervisory Restore Zone 001 [MO2:P109] 35 11/05/2010 07:21 AM Silence Request 36 11/05/2010 07:21 AM Supervisory Off /Norm Zone 001 [MO2:P110] 37 11/05/2010 07:21 AM Supervisory Off/Norm Zone 001 [MO2:P109] 38 11/05/2010 07:21 AM Supervisory Restore Zone 001 [MO2:P1101 39 11/05/2010 07:21 AM Supervisory Restore Zone 001 [MO2:P109] 40 11/05/2010 07:20 AM Silence Request 41 11/05/2010 07:20 AM System Silenced 42 11/05/2010 07:20 AM Silence Request 43 11/05/2010 07:19 AM System Unsilenced 44 11/05/2010 07:19 AM Photo Det Alarm Zone 001 [M33:PO47] 45 11/05/2010 07:19 AM Silence Request 46 11/05/2010 07:19 AM System Silenced 47 11/05/2010 07:18 AM Silence Request 48 11/05/2010 07:18 AM System Unsilenced 49 11/05/2010 07:18 AM Manual Pull Alarm Zone 1 50 11/05/2010 07:18 AM Manual Pull Alarm Zone 001 [M33:P109] 51 11/05/2010 07:17 AM System Silenced 52 11/05/2010 07:17 AM Silence Request 53 11/05/2010 07:17 AM System Unsilenced 54 11/05/2010 07:17 AM Photo Det Alarm Zone 001 [M33:P113] 55 11/05/2010 07:17 AM System Silenced 56 11/05/2010 07:17 AM Silence Request 57 11/05/2010 1 07:17 AM System Unsilenced 58 11/05/2010 I 07:17 AM Photo Det Alarm Zone 001 [M33:P108] 59 11/05/2010 07:16 AM Supervisory Off/Norm Zone 001 [MO2:P112] 60 11/05/2010 07:15 AM System Silenced Account 5820: uploaded on 11/5/2010 7:33:43 AM Page 1 EVENT HISTORY # Date Time Event 61 11/05/2010 07:15 AM _ Silence R uest 62 11/05/2010 07:15 AM System Unsilenced _ 63 11/05/2010 07:15 AM Det Switch Alarm Zone 001 [M33:P009] 64 11/05/2010 07:14 AM Supervisory Restore Zone 001 [MO2:P112] 65 11/05/2010 07:14 AM System Silenced 66 11/05/2010 07:14 AM Silence Request 67 11/05/2010 07:14 AM System Unsilenced 68 11/05/2010 07:14 AM Det Switch Alarm Zone 001 [M33:P010] 69 11/05/2010 07:14 AM Silence Request 70 11/05/2010 07:13 AM Supervisory Off/Norm Zone 001 [MO2:P112] 71 11/05/2010 07:10 AM Output Group Trouble Restore. Group 5 72 11/05/2010 07:10 AM SLC Relay Trbl Rst [M33:P127] 73 11/05/2010 07:10 AM System Silenced 74 11/05/2010 07:10 AM Silence Request 75 11/05/2010 07:10 AM Output Group Trouble Group 5 76 11/05/2010 07:10 AM Detection Alarm Zone 1 77 11/05/2010 07:10 AM SLC Relay Trouble [M33:P127] 78 11/05/2010 07:10 AM Photo Det Alarm Zone 001 [M33:P089] 79 11/05/2010 07:08 AM Water Flow Alarm Zone 1 80 11/05/2010 07:08 AM Water Flow Alarm Zone 001 [M33:P008] 81 11/05/2010 07:07 AM Supv/Tamper Restore Zone 001 [M33:P007] 82 11/05/2010 07:07 AM System Unsilenced 83 11/05/2010 07:07 AM Supv/Tamper Off/Norm Zone 001 [M33:P007] 84 11/05/2010 07:06 AM System Silenced 85 11/05/2010 07:06 AM Silence Request 86 11/05/2010 07:06 AM System Unsilenced 87 11/05/2010 07:06 AM Detection Alarm Restore. Zone 1 88 11/05/2010 07:06 AM Water Flow Alarm Restore. Zone 1 89 11/05/2010 07:06 AM System Reset 90 11/05/2010 07:06 AM Det Switch Alarm Rst Zone 001 [MO2:P058] 91 11/05/2010 07:06 AM Det Switch Alarm Rst Zone 001 MO2:P057 92 11/05/2010 07:06 AM WatFlow Alrm Restore Zone 001 [MO2:P056] 93 11/05/2010 07:06 AM Det Switch Alarm Rst Zone 001 [MO2:P012] 94 11/05/2010 07:06 AM Det Switch Alarm Rst Zone 001 [MO2:P011 ] 95 11/05/2010 07:06 AM User Login Profile 1 96 11/05/2010 07:06 AM User Exited 97 11/05/2010 07:05 AM System Silenced 98 11/05/2010 07:05 AM Silence Request 99 11/05/2010 07:03 AM Det Switch Alarm Zone 001 [MO2:P057] 100 11/05/2010 07:00 AM Det Switch Alarm Zone 001 [MO2:P058] 101 11/05/2010 06:58 AM Det Switch Alarm Zone 001 [MO2:P011] 102 11/05/2010 06:57 AM Detection Alarm Zone 1 103 11/05/2010 06:57 AM Det Switch Alarm Zone 001 [MO2:P012] 104 11/05/2010 06:55 AM Water Flow Alarm Zone 1 105 11/05/2010 06:55 AM Water Flow Alarm Zone 001 [MO2:P056] 106 11/05/2010 06:54 AM Supv/Tamper Restore Zone 001 [MO2:P055] 107 11/05/2010 06:54 AM System Unsilenced 108 11/05/2010 06:54 AM Supv/Tamper Off /Norm Zone 001 [MO2:P055] 109 11/05/2010 06:52 AM System Silenced 110 11/05/2010 06:52 AM Silence Request 111 11/05/2010 06:52 AM - System Unsilenced 112 11/05/2010 1 06:52 AM Detection Alarm Restore. Zone 1 113 11/05/2010 06:52 AM Manual Pull Alarm Restore. Zone 1 114 11/05/2010 06:52 AM Water Flow Alarm Restore. Zone 1 115 11/05/2010 06:52 AM System Reset 116 11/05/2010 06:52 AM Det Switch Alarm Rst Zone 001 [MO2:P107] 117 11/05/2010 06:52 AM Photo Det Alrm Rst Zone 001 [MO2:P071] 118 11/05/2010 06:52 AM Photo Det Alrm Rst Zone 001 [MO2:PO46] 119 11/05/2010 06:52 AM Photo Det Alrm Rst Zone 001 [MO2:P032] 120 11/05/2010 06:52 AM ManPull Alrm Restore Zone 001 [MO2 :P028] 121 11/05/2010 06:52 AM WatFlow Alrm Restore Zone 001 [MO2:P010] Account 5820: uploaded on 11/5/2010 7:33:43 AM Page 2 I' EVENT HISTORY # Date Time Event 122 11/05/2010 06:52 AM WatFlow Alrm Restore Zone 001 [MO2:P007] 123 11/05/2010 06:52 AM Det Switch Alarm Rst Zone 001 [M33:PO40] 124 11/05/2010 06:52 AM Photo Det Alrm Rst Zone 001 [M33:P039] 125 11/05/2010 06:52 AM User Login Profile 1 126 11/05/2010 06:52 AM User Exited 127 11/05/2010 06:51 AM System Silenced 128 11/05/2010 06:51 AM Silence Request 129 11/05/2010 06:50 AM Det Switch Alarm Zone 001 [MO2:P107] 130 11/05/2010 06:49 AM Photo Det Alarm Zone 001 [MO2:P071] 131 11/05/2010 06:48 AM Manual Pull Alarm Zone 1 132 11/05/2010 06:48 AM Manual Pull Alarm Zone 001 [MO2:P028] 133 11/05/2010 06:47 AM WatFlow Alrm Restore Zone 001 [M33:P001] 134 11/05/2010 06:46 AM Water Flow Alarm Zone 001 [M33:P001] 135 11/05/2010 06:46 AM Water Flow Alarm Zone 001 [MO2:P010] 136 11/05/2010 06:45 AM Supv/Tamper Restore Zone 001 [MO2:P009] 137 11/05/2010 06:45 AM Supv/Tamper Off /Norm Zone 001 [MO2:P009] 138 11/05/2010 06:44 AM Photo Det Alarm Zone 001 [MO2:P032] i 139 11/05/2010 06:42 AM Photo Det Alarm Zone 001 [MO2:PO46] 140 11/05/2010 06:39 AM Det Switch Alarm Zone 001 [M33:PO40] 141 11/05/2010 06:36 AM Supv/Tamper Restore Zone 001 [M33:P028] 142 11/05/2010 06:36 AM Supv/Tamper Off /Norm Zone 001 [M33:P028] 143 11/05/2010 06:35 AM Supv/Tamper Restore Zone 001 [M33:P027] 144 11/05/2010 06:35 AM Supv/Tamper Off/Norm Zone 001 [M33:P027] 145 11/05/2010 06:34 AM Detection Alarm Zone 1 146 11/05/2010 06:34 AM Photo Det Alarm Zone 001 [M33:P039] 147 11/05/2010 06:32 AM Water Flow Alarm Zone 1 148 11/05/2010 06:32 AM Water Flow Alarm Zone 001 [MO2:P007] 149 11/05/2010 06:31 AM Supv/Tamper Restore Zone 001 [MO2:P006] 150 11/05/2010 06:31 AM Supv/Tamper Off/Norm Zone 001 [MO2:P006] 151 11/05/2010 06:31 AM Supv/Tamper Restore Zone 001 [MO2:P006] 152 11/05/2010 06:30 AM System Unsilenced 153 11/05/2010 06:30 AM Supv/Tamper Off /Norm Zone 001 [MO2:P006] 154 11/05/2010 06:26 AM Silence Request 155 11/05/2010 06:25 AM Output Group Trouble Group 1 156 11/05/2010 06:25 AM SLC Relay Disabled [MO2:P111] 157 11/05/2010 06:25 AM SLC Relay Trouble [MO2:P111] 158 11/05/2010 06:25 AM SLC Relay Disabled [M33:P025] 159 11/05/2010 06:25 AM SLC Relay Trouble [M33:P025] 160 11/05/2010 06:25 AM SLC Relay Disabled [M33:P012] 161 11/05/2010 06:25 AM SLC Relay Trouble [M33:P012] 162 11/05/2010 06:25 AM SLC Relay Disabled [M33:P006] 163 11/05/2010 06:25 AM SLC Relay Trouble [M33:P006] 164 11/05/2010 06:25 AM SLC Relay Disabled [M33:P005] 165 11/05/2010 06:25 AM SLC Relay Trouble [M33:P005] 166 11/05/2010 06:25 AM SLC Relay Disabled [M33:P004] 167 11/05/2010 06:25 AM SLC Relay Trouble [M33:P004] 168 11/05/2010 06:25 AM SLC Relay Disabled [M33:P003] 169 11/05/2010 06:25 AM SLC Relay Trouble [M33:P003] 170 11/05/2010 06:25 AM Output Pt Disabled Group 001 M34:P008] 171 11/05/2010 06:25 AM Notification Trouble Group 001 [M34:P008] 172 11/05/2010 06:25 AM Output Pt Disabled Group 001 [M34:P007] 173 11/05/2010 06:25 AM Notification Trouble Group 001 [M34:P007] 174 11/05/2010 06:25 AM Output Pt Disabled Group 001 [M34 :P005] 175 11/05/2010 06:25 AM Notification Trouble Group 001 [M34:P005] 176 11/05/2010 _ 06:25 AM Output Pt Disabled Group 001 [M34:P004] 177 11/05/2010 06:25 AM Notification Trouble Group 001 [M34:P004] 178 11/05/2010 06:25 AM Output Pt Disabled Group 001 [M34:P003] 179 11/05/2010 06:25 AM Notification Trouble Group 001 [M34:P003] 180 11/05/2010 06:25 AM Output Pt Disabled Group 001 [M34:P002] 181 11/05/2010 06:25 AM Notification Trouble Group 001 [M34:P002] 182 11/05/2010 06:25 AM Output Pt Disabled Group 001 [M34:P001] Account 5820: uploaded on 11/5/2010 7:33:43 AM Page 3 i EVENT HISTORY # Date Time Event 183 11/05/2010 06:25 AM Notification Trouble Group 001 [M34:P001] 184 11/05/010 06:25 AM System Silenced 185 11/05/2010 06:25 AM Silence Request 186 11/05/2010 06:25 AM System Unsilenced _ 187 11/05/2010 06:25 AM Detection Alarm Restore. Zone 1 188 11/05/2010 06:25 AM System Reset 189 11/05/2010 06:25 AM Photo Det Alrm Rst Zone 001 [MO2:P003] 190 11/05/2010 06:25 AM User Login Profile 1 191 11/05/2010 06:25 AM User Exited 192 11/05/2010 06:25 AM User Login Profile 1 193 11/05/2010 06:25 AM System Silenced 194 11/05/201p 06:25 AM Silence Request 195 11/05/2010 06:25 AM User Exited 196 11/05/201b 06:25 AM User Login Profile 3 197 11/05/201;0 06:17 AM System Unsilenced 198 11/05/2010 06:17 AM Detection Alarm Zone 1 199 11/05/2010 06:17 AM Photo Det Alarm Zone 001 [MO2:P003] 200 11/05/2010 06:12 AM User Exited 201 11/05/2010 06:09 AM User Login Profile 3 202 11/05/2010 02:00 AM Auto Test Off -Norm 203 11/04/201;0 03:55 PM User Exited 204 11/04/2010 03:54 PM User Login Profile 3 205 11/04/2010 03:54 PM User Exited Account 5820: uploaded on 11/5/2010 7:33:43 AM Page 4 • Frank King fP$02/o (b/ 4 F rom: Stuart Lacey [StuartL@e2systemsllc.corn] - Sent: Monday, November 08, 2010 10:01 AM . 4 To Frank King Subject:' record of completion. Attachments: = ACS.doc 1108094928_001 .pdf • Frank:' The word doc is the whole' Completion form and the pdf is pages 10 and 11 with s on them . you need to sign on page 12. • Ifyou.have any que please.call me /� /-1 • V I • Stuart Lacy <' j0 0 • , E Squared systems • • Ph /53-677-5946 . • • • • ' . • c 1 _ FIRE ALARM AND EMERGENCY COMMUNICATION SYSTEM RECORD OF COMPLETION To be completed by the system 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. • 1. PROPERTY INFORMATION Name of property: ACS Address: 13333 SW 66'" PARKWAY TIGARD OR 97223 Description of property: 2 FLOOR LAN ROOM Occupancy type: COMERCIAL Name of property representative: FRANK KING , SD DEACON CORP. Address: 901 NE GILSAN ST SUITE 100 Phone: 503 -297 -8791 Fax: 503 -297 -8997 E -mail: VWWV.deacon.com Authority having jurisdiction over this property: CITY OF TIGARD Phone: Fax: E -mail: 2. INSTALLATION, SERVICE, AND TESTING CONTRACTOR INFORMATION Installation contractor for this equipment: E SQUARED SYSTEMS Address: 10111 S. TACOMA WAY SUITE D-6 , TACOMA WA 98449 License or certification number: 192211 Phone: 253- 284 -3707 Fax: 253 - 284-3714 E -mail: WWW.e2systemslic.com Service organization for this equipment: E SQUARED SYSTEMS Address: 10111 s TACOMA WAY , SUITE D -6, TACOMA WA 98449 License or certification number: 192211 Phone: 253-284-3707 Fax: 253 - 284-3714 E -mail: WVVW.e2systemslIc.com A contract for test and inspection in accordance with NFPA standards is in effect as of: N/A Contracted testing company: Address: Phone: Fax: E -mail: Contract expires: Contract number: Frequency of routine inspections: 3. DESCRIPTION OF SYSTEM OR SERVICE ❑ Fire alarm system (nonvoice) ❑ Fire alarm with in- building fire emergency voice alarm communication system (EVACS) ❑ Mass notification system (MNS) ❑ Combination system, with the following components: ❑ Fire alarm ❑ EVACS ❑ MNS ❑ Two -way, in- building, emergency communication system Other (specify): FIKE FM -200 SYSTEM NFPA J2, Fig. 1018.2: 1 (p. 1 of 12) Copyright ® 2009 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. 3. DESCRIPTION OF SYSTEM OR SERVICE (continued) NFPA 72 edition: 2007 Additional description of system(s): 3.1 Control Unit Manufacturer: FIKE Model number: SHP PRO 3.2 Mass Notification System ® This system does not incorporate an MNS 3.2.1 System Type: ❑ In- building MNS-- combination ❑ In- building MNS —stand -alone ❑ Wide -area MNS ❑ Distributed recipient MNS ❑ Other (specify): 3.2.2 System Features: ❑ Combination fire alarm/MNS ❑ MNS autonomous control unit ❑ Wide -area MNS to regional national alerting interface ❑ Local operating console (LOC) ❑ Direct recipient MNS ( DRMNS) ❑ Wide -area MNS to DRMNS interface ❑ Wide -area MNS to high -power speaker array (HPSA) interface ❑ In- building MNS to wide -area MNS interface ❑ Other (specify): 3.3 System Documentation P_ An owner's manual, a copy of the manufacturer's instructions, a written sequence of operation, and a copy of the numbered record drawings are stored on site. Location: AT PANEL 3.4 System Software ® This system does not have alterable site - specific software. Operating system (executive) software revision level: Site- specific software revision date: Revision completed by: ❑ A copy of the site - specific software is stored on site. Location: 3.5 Off - Premises Signal Transmission ® This system does not have off -premises transmission. Name of organization receiving alarm signals with phone numbers: Alarm: Phone: Supervisory: Phone: Trouble: Phone: Entity to which alarms are retransmitted: Phone: Method of retransmission: If Chapter 26, specify the means of transmission from the protected premises to the supervising station: If Chapter 27, specify the type of auxiliary alarm system: ❑ Local energy ❑ Shunt ❑ Wired ❑ Wireless NFPA 72, Fig. 10.18.2.1.1 (p. 2 of 12) Copyright 0 2009 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. 4. CIRCUITS AND PATHWAYS 4.1 Signaling Line Pathways 4.1.1 Pathways Class Designations and Survivability Pathways class: Survivability level: Quantity: (See NFPA 72, Sections 12.3 and 12.4) 4.1.2 Pathways Utilizing Two or More Media Quantity: N/A Description: 4.1.3 Device Power Pathways ® No separate power pathways from the signaling line pathway ❑ Power pathways are separate but of the same pathway classification as the signaling line pathway ❑ Power pathways are separate and different classification from the signaling line pathway 4.1.4 Isolation Modules Quantity: N/A 4.2 Alarm Initiating Device Pathways 4.2.1 Pathways Class Designations and Survivability Pathways class: B Survivability level: Quantity: 2 • (See NFPA 72, Sections 12.3 and 12.4) 4.2.2 Pathways Utilizing Two or More Media Quantity: Description: 4.2.3 Device Power Pathways ® No separate power pathways from the initiating device pathway ❑ Power pathways are separate but of the same pathway classification as the initiating device pathway ❑ Power pathways are separate and different classification from the initiating device pathway 4.3 Non -Voice Audible System Pathways 4.3.1 Pathways Class Designations and Survivability Pathways class: N/A Survivability level: Quantity: (See NFPA 72, Sections 12.3 and 12.4) 4.3.2 Pathways Utilizing Two or More Media Quantity: N/A Description: 4.3.3 Device Power Pathways ® No separate power pathways from the notification appliance pathway ❑ Power pathways are separate but of the same pathway classification as the notification appliance pathway ❑ Power pathways are separate and different classification from the notification appliance pathway NFPA, 72, Fig. 10,18.2.1 1 (p. 3 of 12) Copyright ®2009 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. ,iii • „/ 5. ALARM INITIATING DEVICES 5.1 Manual Initiating Devices 5.1.1 Manual Fire Alarm Boxes ❑ This system does not have manual fire alarm boxes. Type and number of devices: Addressable: Conventional: 1 Coded: Transmitter: Other (specify): 5.1.2 Other Alarm Boxes ® This system does not have other alarm boxes. Description: Type and number of devices: Addressable: Conventional: Coded: Transmitter: Other (specify): 5.2 Automatic Initiating Devices 5.2.1 Smoke Detectors ❑ This system does not have smoke detectors. Type and number of devices: Addressable: Conventional: 2 Other (specify): Type of coverage: ® Complete area ❑ Partial area ❑ Nonrequired partial area Other (specify): Type of smoke detector sensing technology: ❑ Ionization ® Photoelectric ❑ Multicriteria ❑ Aspirating ❑ Beam Other (specify): 5.2.2 Duct Smoke Detectors ® This system does not have alarm- causing duct smoke detectors. Type and number of devices: Addressable: Conventional: Other (specify): Type of coverage: Type of smoke detector sensing technology: ❑ Ionization ❑ Photoelectric ❑ Aspirating ❑ Beam 5.2.3 Radiant Energy (Flame) Detectors ® This system does not have radiant energy detectors. Type and number of devices: Addressable: Conventional: Other (specify): Type of coverage: 5.2.4 Gas Detectors ® This system does not have gas detectors. Type of detector(s): Number of devices: Addressable: Conventional: Type of coverage: 5.2.5 Heat Detectors 0 This system does not have heat detectors. Type and number of devices: Addressable: Conventional: Type of coverage: ❑ Complete area ❑ Partial area ❑ Nonrequired partial area ❑ Linear ❑ Spot Type of heat detector sensing technology: ❑ Fixed temperature ❑ Rate -of -rise ❑ Rate compensated NFPP 72, Fig. 10.18.2.1.1 (p. 4 of 12) Copyright 02009 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. 5. ALARM INITIATING DEVICES (continued) 5.2.6 Addressable Monitoring Modules ® This system does not have monitoring modules. Number of devices: 5.2.7 Waterflow Alarm Devices ® This system does not have waterflow alarm devices. Type and number of devices: Addressable: Conventional: Coded: Transmitter: 5.2.8 Alarm Verification ® This system does not incorporate alarm verification. Number of devices subject to alarm verification: Alarm verification set for: seconds 5.2.9 Presignal ►_ This system does not incorporate pre- signal. Number of devices subject to presignal: Describe presignal functions: 5.2.10 Positive Alarm Sequence (PAS) ® This system does not incorporate PAS. Describe PAS: 5.2.11 Other Initiating Devices ® This system does not have other initiating devices. . Describe: 6. SUPERVISORY SIGNAL INITIATING DEVICES 6.1 Sprinkler System Supervisory Devices ® This system does not have sprinkler supervisory devices. Type and number of devices: Addressable: Conventional: Coded: Transmitter: Other (specify): 6.2 Fire Pump Description and Supervisory Devices ® This system does not have a fire pump. Type fire pump: ❑ Electric pump ❑ Engine Type and number of devices: Addressable: Conventional: Coded: Transmitter: Other (specify): 6.2.1 Fire Pump Functions Supervised ❑ Power ❑ Running ❑ Phase reversal ❑ Selector switch not in auto ❑ Engine or control panel trouble ❑ Low fuel Other (specify): 6.3 Duct Smoke Detectors (DSDs) ❑ This system does not have DSDs causing supervisory signals. Type and number of devices: Addressable: Conventional: Other (specify): Type of coverage: Type of smoke detector sensing technology: ❑ Ionization ❑ Photoelectric ❑ Aspirating ❑ Beam 6.4 Other Supervisory Devices ❑ This system does not have other supervisory devices. Describe: PANEL DISCONNECT SWITCH NF PA 72, Fig. 10.18.2 1.1 (p..= of 12) Copyright ® 2009 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. 7. MONITORED SYSTEMS 7.1 Engine -Driven Generator ® This system does not have a generator. 7.1.1 Generator Functions Supervised ❑ Engine or control panel trouble ❑ Generator running ❑ Selector switch not in auto ❑ Low fuel ❑ Other (specify): 7.2 Special Hazard Suppression Systems ❑ This system does not monitor special hazard systems. . Description of special hazard system(s): 7.3 Other Monitoring Systems ❑ This system does not monitor other systems. Description of special hazard system(s): 8. ANNUNCIATORS ® This system does not have annunciators. 8.1 Location and Description of Annunciators Location 1: Location 2: Location 3: 9. ALARM NOTIFICATION APPLIANCES 9.1 In- Building Fire Emergency Voice Alarm Communication System ® This system does not have an EVACS. Number of single voice alarm channels: Number of multiple voice alarm channels: Number of speakers: Number of speaker circuits: Location of amplification and sound - processing equipment: Location of paging microphone stations: Location 1: Location 2: Location 3: 9.2 Nonvoice Notification Appliances ❑ This system does not have nonvoice notification appliances. Horns: 1 With visible: 2 Bells: With visible: Chimes: With visible: Visible only: Other (describe): 9.3 Notification Appliance Power Extender Panels ® This system does not have power extender panels. Quantity: Locations: NFF-'A 72, Pig. 10.1S.E.1.1 (p. ' of 12) Copyright C 2008 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. 10. MASS NOTIFICATION CONTROLS, APPLIANCES, AND CIRCUITS ® This system does not have an MNS. 10.1 MNS Local Operating Consoles Location 1: Location 2: Location 3: 10.2 High - Power Speaker Arrays Number of HPSA speaker initiation zones: • Location 1: Location 2: Location 3: 10.3 Mass Notification Devices Combination fire alarm/MNS visible appliances: MNS -only visible appliances: Textual signs: Other (describe): Supervision class: 10.3.1 Special Hazard Notification ❑ This system does not have special suppression predischarge notification. ❑ MNS systems DO NOT override notification appliances required to provide special suppression predischarge notification. 11. TWO EMERGENCY COMMUNICATION SYSTEMS 11.1 Telephone System . ® This system does not have a two-way telephone system. Number of telephone jacks installed: Number of warden stations installed: Number of telephone handsets stored on site: . Type of telephone system installed: ❑ Electrically powered ❑ Sound powered 11.2 Two Radio Communications Enhancement System ❑ This system does not have a two -way radio communications enhancement system. Percentage of area covered by two -way radio service: Critical areas: % General building areas: Amplification component locations: Inbound signal strength: dBm Outbound signal strength: dBm Donor antenna isolation is: dB above the signal booster gain Radio frequencies covered: Radio system monitor panel location: NFPA 72, Fig. 10.18.2.1.1 (p. 7 of 12) Copyright © 2009 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. 11. TWO -WAY EMERGENCY COMMUNICATION SYSTEMS (continued) 11.3 Area of Refuge (Area of Rescue Assistance) Emergency Communications Systems ❑ This system does not have an area of refuge (area of rescue assistance) emergency communications system. Number of stations: Location of central control point: Days and hours when central control point is attended: Location of alternate control point: Days and hours when alternate control point is attended: 11.4 Elevator Emergency Communications Systems ❑ This system does not have an elevator emergency communications system. Number of elevators with stations: Location of central control point: Days and hours when central control point is attended: Location of alternate control point: Days and hours when alternate control point is attended: 11.5 Other Two -Way Communication Systems Describe: 12. CONTROL FUNCTIONS . This system activates the following control fuctions: ❑ Hold -open door releasing devices ❑ Smoke management ®HVAC shutdown ❑ F/S dampers ❑ Door unlocking ❑ Elevator recall ❑ Fuel source shutdown ® Extinguishing agent release ❑ Elevator shunt trip ❑ Mass notification system override of fire alarm notification appliances Other (specify): 12.1 Addressable Control Modules ® This system does not have control modules. Number of devices: Other (specify): 13. SYSTEM POWER 13.1 Control Unit 13.1.1 Primary Power Input voltage of control panel: 120 VAC Control panel amps: 20 Overcurrent protection: Type: CIRCUIT BREAKER Amps: 20 Location (of primary supply panel board): 2 FLOOR LAN ROOM Disconnecting means location: 2ND FLOOR ELECTRICAL ROOM 13.1.2 Engine - Driven Generator ® This system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: NFPP4 72, Hg. 10.18.2.1 1 (p. o of 12) Copyright Cr 2009 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. 13. SYSTEM POWER (continued) 13.1.3 Uninterruptible Power System ® This system does not have a UPS. Equipment powered by a UPS system: Location of UPS system: Calculated capacity of UPS batteries to drive the system components connected to it: In standby mode (hours): In alarm mode (minutes): 13.1.4 Batteries Location: SHP PANEL Type: GEL CELL Nominal voltage: 12 Amp/hour rating: 7.5 Calculated capacity of batteries to drive the system: In standby mode (hours): 24 HRS In alarm mode (minutes): 10 MIN ® Batteries are marked with date of manufacture ❑ Battery calculations are attached 13.2 In- Building Fire Emergency Voice Mann Communication System or Mass Notification System ►'. This system does not have an EVACS or MNS system. 13.2.1 Primary Power Input voltage of EVACS or MNS panel: EVACS or MNS panel amps: Overcurrent protection: Type: Amps: Location (of primary supply panel board): Disconnecting means location: 13.2.2 Engine - Driven Generator ❑ This system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: 13.2.3 Uninterruptible Power System ® This system does not have a UPS. Equipment powered by a UPS system: Location of UPS system: Calculated capacity of UPS batteries to drive the system components connected to it: In standby mode (hours): In alarm mode (minutes): 13.2.4 Batteries Location: Type: Nominal voltage: Amp/hour rating: Calculated capacity of batteries to drive the system: In standby mode (hours): In alarm mode (minutes): ❑ Batteries are marked with date of manufacture ❑ Battery calculations are attached %N'FP».. 72, Fig. 17.18.2 1 1 (p. 9 of 12) Copyright ® 2008 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. 13. SYSTEM POWER (continued) 13.3 Notification Appliance Power Extender Panels ® This system does not have power extender panels. 13.3.1 Primary Power Input voltage of power extender panel(s): Power extender panel amps: Overcurrent protection: Type: Amps: Location (of primary supply panel board): Disconnecting means location: 13.3.2 Engine -Driven Generator ® This system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: 13.3.3 Uninterruptible Power System ® This system does not have a UPS. Equipment powered by a UPS system: Location of UPS system: Calculated capacity of UPS batteries to drive the system components connected to it: In standby mode (hours): In alarm mode (minutes): 13.3.4 Batteries Location: Type: Nominal voltage: Amp/hour rating: Calculated capacity of batteries to drive the system: In standby mode (hours): In alarm mode (minutes): ❑ Batteries are marked with date of manufacture ❑ Battery calculations are attached 14. 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 confucting operational acceptance tests. This is a: ® New system ❑ Modification to an existing system Permit number: The system has been installed in accordance with the following requirements: (Note any or all that apply.) NFPA 72, Edition: 2007 ® NFPA 70, National Electrical Code, Article 760, Edition: 2008 ® Manufacturer's published instructions Other (specify): System deviations from referenced NFPA standards: N/A Signed: Printed name: STUART LACY Date: NOV 5 10 Organization: E SQUARED SYSTEMS Title: TECH Phone: 253 -677 -5946 AAA 72, Fig. 1018.2 1.1 (p. 10 of 12) Copyright ® 2009 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. 15. RECORD OF SYSTEM OPERATIONAL ACCEPTANCE TEST ® New system 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 for the following: 0 Modifications to an existing system All newly modified operational features and functions of the 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 the following: • NFPA 72, Edition: 2007 ® NFPA 70, National Electrical Code, Article 760, Edition: 2008 ® Manufacturer's published instructions Other (specify): ® Individual device testing documentation [Inspection and Testing Form (Figure 14.6.2.4) is attached] Signed: Printed name: STUART LACY Date: NOV 5 10 Organization: E SQUARED Title: TECH Phone: 253 - 677 -5946 16. CERTIFICATIONS AND APPROVALS 16.1 System Installation Contractor: This system, as specified herein, has been installed and tested according to all NFPA standards cited herein. Signed: Printed name: STUART LACY Date: NOV 5 10 Organization: E SQUARED Title: TECH Phone: 253 -677 -5946 16.2 System Service Contractor: The undersigned has a service contract for this system in effect as of the date shown below. Signed: N/A Printed name: Date: Organization: Title: Phone: 16.3 Supervising Station: This system, as specified herein, will be monitored according to all NFPA standards cited herein. Signed: N/A Printed name: Date: Organization: Title: Phone: • Copyright ©2009 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. • • 16. CERTIFICATIONS AND APPROVALS (continued) 16.4 Property or Owner Representative: • This system, as sp cified h in, will be monitored according to all NFPA standards cited herein" • Signed: • Printed name: FRANK KING Date: NOV 5 10 Organization: SD DEACON Title: SUPERINTENDENT Phone: 503 = 297-8791 • - 16.5 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, with its approved sequence of operations, and with all NFPA standards cited herein. • Signed: Printed name: Date: NOV 5 10 Organization: Title: Phone: • • • • • - I • • • • • • NFPA 72, Hg 10.18.2.1.11 %;;. 12 ct 12) I _ • Copynght ® 2009 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. • 15. RECORD OF SYSTEM OPERATIONAL ACCEPTANCE TEST ® New system 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 for the following: ® Modifications to an existing system All newly modified operational features and functions of the 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 the following: ►:� NFPA 72, Edition: 2007 ►'� NFPA 70, National Electrical Code, Article 760, Edition: 2008 ® Manufacturer's published instructions Other (specify): 0 Individual devic esting do umentation [Inspection and Testing Form (Figure 14.6.2.4) is attached] Signed: Printed name: STUART LACY Date: NOV 5 10 Organization: E SQUARED Title: TECH Phone: 253 - 677 -5946 16. CERTIFICATIONS AND APPROVALS 16.1 System Installation Contractor: This system, as specified herein, has been installed and tested according to all NFPA standards cited herein. Signed: , Printed name: STUART LACY Date: NOV 5 10 Organization: E SQUARED Title: TECH Phone: 253 -677 -5946 16.2 System Service Contractor: The undersigned has a service contract for this system in effect as of the date shown below. Signed: N/A Printed name: Date: Organization: Title: Phone: 16.3 Supervising Station: This system, as specified herein, will be monitored according to all NFPA standards cited herein. Signed: N/A Printed name: Date: Organization: Title: Phone: i NFPA 72. Fig J. 8.2.1 1 ip I of ' - Copyright @ 2009 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 13. SYSTEM POWER (continued) 13.3 Notification Appliance Power Extender Panels T This system does not have power extender panels. 13.3.1 Primary Power Input voltage of power extender panel(s): Power extender panel amps: Overcurrent protection: Type: Amps: Location (of primary supply panel board): Disconnecting means location: 13.3.2 Engine - Driven Generator ® This system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: 133.3 Uninterruptible Power System ® This system does not have a UPS. Equipment powered by a UPS system: Location of UPS system: Calculated capacity of UPS batteries to drive the system components connected to it: In standby mode (hours): in alarm mode (minutes): 13.3.4 Batteries Location: Type: Nominal voltage: Amp/hour rating: Calculated capacity of batteries to drive the system: In standby mode (hours): In alarm mode (minutes): ❑ Batteries are marked with date of manufacture ❑ Battery calculations are attached 14. 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 confucting operational acceptance tests. This is a: ® New system ❑ Modification to an existing system Permit number: The system has been installed in accordance with the following requirements: (Note any or all that apply.) o A'FPA 72, Edition: 2007 . ® A'FPA 70, National Electrical Code, Article 760, Edition: 2006 ® Manufacturer's published instructions Other (specify): System deviations from referenced NFPA standards: N/A �' Z Printed name: STUART LACY Date: NOV 5 10 Signed: � �� i Organization: E SQU - ED SYSTEMS Title: TECH Phone: 253- 677 -5946 I JVFPA. 72, Fig 10.1S2 1.1 (p 10 of 12) Copyright ® 2009 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