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Report EPS o jZ -e9-0 I Z L ( 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 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. 1. PROPERTY INFORMATION ,/� Name of property: 4500;40 r Address: g9 - GI f (Q 5 J Pkto CT esvo& Description of property: E Oct-- Occupancy type: Name of property representative: Address: Phone: Fax: E-mail: Authority having jurisdiction over this property: Phone: Fax: E-mail: 2. INSTALLATION, SERVICE, AND TESTING CONTRACTOR INFORMATION Installation contractor for this equipment: ' '(z ;E4-4 SG 1.42 3 � ` - �y Address: \3 a— v..�TV 3 612- c Ccr O 2_ License or certification number: CC S \V Phone: - Fax: E-mail: Service organization for this equipment: S/ t h, Address: License or certification number. Phone: Fax: E-mail: A contract for test and inspection in accordance with NFPA standards is in effect as of: Contracted testing company: 5p `t Address: Phone: Fax: E-mail: Contract expires: Contract number. Frequency of routine inspections: 3. DESCRIPTION OF SYSTEM OR SERVICE ire 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 (spay): Copyrt9M ® 2009 National Fire Protection Association. This form may be copied for Individual use other than for resale. It may not be copied for aarnrnerdal sale or distribution. 3. DESCRIPTION OF SYSTEM OR SERVICE (continued) NFPA 72 edition: `2_0 \ 0 Additional description of system(s): 3.1 Control Unit Manufacturer: '\i tR v i ZG Model number. V1 O'S– 0 3.2 Mass Notification Systems 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 (LAC) ❑ 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): 33 System Documentation 10<n 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: . C,. Q . 3A 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 2 copy of the site - specific software is stored on site. Location: T . A _ C . Y . 3.5 Off - Premises Signal Transmission ❑ This system does not have off - premises transmission. Name of organization receiving alarm signals with phone numbers: (�(>�v' -P4 Alarm: H NI A +J'r(0 - LA. D1/4c Phone: .8 1 •2O - Cl i' \ Supervisory: t` Phone: . Trouble: t • 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: A g5 2A-0 S & c TrieYL_ If Chapter 27, specify the type of auxiliary alarm system: ❑ Local energy ❑ Shunt ❑ Wired ❑ Wireless Copyright 0 2009 Natbnm Fire Protection association. This farm may be coped for individual use other than for resale. It may not be coped 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: `Q Quantity: (See NFPA 72, Sections 12.3 and 12.4) 4.1.2 Pathways Utilizing Two or More Media Quantity: Description: 4.1.3 Device Power Pathways ffNo 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: 4.2 Alarm Initiating Device Pathways 4.2.1 Pathways Class Designations and Survivability Pathways class: t?j Survivability level: YS< Quantity: (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 ®'P o � 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 43.1 Pathways Class Designations and Survivability Pathways class: Survivability level: Quantity: Z (See NFPA 72, Sections 12.3 and 12.4) 4.3.2 Pathways Utilizing Two or More Media Quantity: Description: 44-333 Appliance Power Pathways g 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 Copyright 02009 National Are Protection Association. This form may be coped for Individual use Wier than for resale. It may not be coped for commercial sale or dlstrib tlon. 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: 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 I ❑ This system does not have smoke detectors. Type and number of devices: Addressable: % Conventional: Other (specify): -- Type of coverage: ❑ Complete area ('Partial area ❑ Nonrequired partial area Other (specify): Type of smoke detector sensing technology: ❑ Ionization hotoelectric ❑ Multicriteria ❑ Aspirating ❑ Beam Other (specify): 5.2.2 Duct Smoke Detectors Ibis 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 ❑ Photoel ectric ❑ Aspirating ❑ Beam 5.2.3 Radiant Energy (Flame) Detectors l21bis / system does not have radiant energy detectors. Type and number of devices: Addressable: Conventional: Other (specify): Type of coverage: 5.2.4 Gas Detectors ETibis system does not have gas detectors. Type of detector(s): Number of devices: Addressable: Conventional: Type of coverage: 5.2.5 Heat Detectors 6a'6; 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 Copyright ® 2009 National Fire Protection Association. This form may be copied far IMvtaual use inner than for resale. 11 may not oe copied for co nrnoraal sale or distribution. 5. ALARM INITIATING DEVICES (continued) 5.2.6 Addressable Monitoring Modules ❑ This system does not have monitoring modules. Number of devices: L 5.2.7 Watertlow Alarm Devices ❑ This system does not have waterflow alarm devices. Type and number of devices: Addressable: t Conventional: Coded: Transmitter. 5.2.8 Alarm Verification system does not incorporate alarm verification. Number of devices subject to alarm verification: 6/ Alarm verification set for seconds 5.2.9 Presignal (Ks system does not incorporate pre- signal. Number of devices subject to pm-signal: Describe presignal functions: 5.2.10 Positive Alarm Sequence (PAS) Begs system does not incorporate PAS. Describe PAS: _/ 5.2.11 Other Initiating Devices Ly11 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 B11 s 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) CE Ks 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 E Ibis system does not have other supervisory devices. Describe: Copyright ®2009 National Re Protection Association. This form may he cople0 far tiltllvldual use other man for resale. It may not De copied for commeraai sale or distribution. 7. MONITORED SYSTEMS 7.1 Engine- Driven Generator is 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 Systemss system does not monitor special hazard systems. Description of special hazard system(s): 7.3 Other Monitoring Systems EirlThcsystem does not monitor other systems. Description of special hazard system(s): 8. ANNUNCIATORS 13 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 8"ihis 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 o This system does not have nonvoice notification appliances. Horns: let (J With visible: 0 Bells: I N With visible: Chimes: With visible: Visible only: Other (describe): ,,��� 93 Notification Appliance Power Extender Panels Inrs system does not have power extender panels. Quantity: Locations: Copyright 02009 Naaotal Fae Protector Awn. This form may be coped for individual use other than for resale. It may not be copied for aorfrretdal sale or dSClallon. 10. MASS NOTIFICATION CONTROLS, APPUANCES, AND CIRCUITS 1 is 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: 103 Mass Notification Devices Combination fire alarm/MNS visible appliances: MNS -only visible appliances: Textual signs: Other (describe): Supervision class: 103.1 Hazard Notification t J 'ibi� system does not have special suppression predischarge notification. 'N / fNS systems DO NOT override notification appliances required to provide special suppression predischarge notification. 11. TWO -WAY EMERGENCY COMMUNICATION SYSTEMS 111 Telephone System stem 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-Way Radio Communications Enhancement System 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: Copyright 02009 National Fire Protection Association. This tam nay be copied for individual use oilier than for resale. It nay not be coped for commercial sale or distribution. 11. TWO -WAY EMERGENCY COMMUNICATION SYSTEMS (continued) 113 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 r 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 lir‹ 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: i t O /� A t. Control panel amps: Co fJ Overcurrent protection: Type: t ; . n� Amps: pQ 0 !(!! Location ( o f primary supply panel board): ` G , / l i �i4t l i . t�trv� tAoAcs, PA ?.s L. % t2__ \ Disconnecting means location: ,� +rms s _� 13.1.2 Engine-Driven Generator �dystem does not have a generator. Location of generator: Location of fuel storage: Type of fuel: Copyright 02009 National Rre Protedlon Assodaton. This torm may be copied for Int9Ndual use other than to resale. It nay not be coped for mmr urdal sale or dlsbibulton 13. SYSTEM POWER (continued) �� 13.13 Uninterruptlble Power System 1 is 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: . A , t , . Type: S L- A _ Nominal voltage: 1 \J 8 i ✓ Amp/hour rating: -7 4 . _ Calculated capacity of batteries to drive the system: In standby mode (hours): a1.1 s / In alarm mode (minutes): E atteries are marked with date of manufacture Battery calculations are attached 13.2 In-Building Fire Emergency Voice Alarm Communication System or Mass Notification System GPrl In 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 s system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: 13.23 Umnterruptible Power System ErTttis 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 0 Battery calculations are attached Copyrtght ® 2009 National Fire Protection Association. This tam may be odd for bhdirbual use other than for resale. It may not be coped to commercial sale cc distribution. . 13. SYSTEM POWER (continued) 13.3 Notification Appliance Power Extender Panels B1 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 Generator ( ibis system does not have a generator. Location of generator. Location of fuel storage: Type of fuel: 1333 Uninterruptlble Power Systems 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): 133.4 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 conducting operational acceptance tests. This is a: fit V v system 0 Modification to an existing system Permit number. The s stem has been installed in accordance with the following requirements: (Note any or all that apply.) NFPA 72, Edition: der' tO +FP 70, National Electrical Code, Article 760, Edition: Manufacturer's published instructions Other (specify): System deviation il. referenced NFPA standards: Signed.`] `Tr t r n Printed name: S Mov■riv�% Date: l` ( \Z'- Organization: W . 5 , V , C • Title: xSa, i\ l SEA Phone: q 7 1- 2Z r- 'moqD copyright 02009 National File Protetnm Association. This farm may be coped for individual use other than to resale. It may not be tepee for t sn erdal sale Of osarormon. . 15. RECORD OF SYSTEM OPERATIONAL ACCEPTANCE TEST ew 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 requi7ents of the following: FPA 72, Edition: FPA 70, National Electrical Code, Article 760. Edition: l'IVlanufacturer's published instructions Other (specify): ❑ Individual devi • testing documentation [Inspection and Testing Form (Figure 14.6.2.4) is attached] Signed F I ' Printed name: 3 L a`t`o LO �L Date: l \ ") 1'1_0 ; Z� Organization: \,) , S . . e - Title: kk - ' - k - S3 \.( Phone: '1 \ •-`1-- — 0 16. CERTIFICATIONS AND APPROVALS e 16.1 System Installation Contractor. V r 5 + F4 This system, as s' • ed herein, has been installed and tested according to all NFPA standards cited herein. Signed: XI i 1 • Printed name: S tart M v v‹ ,O t. ..Date: t� l � \' 6 { Z Organization: i .5.. 2 9 . Title: l 4453 LEA Phone: q 1 k . ZZ` - 5 [ 3z) 16.2 System Service Contractor. The undersigned has a service contract for this system in effect as of the date shown below. Signed: Printed name: Date: Organization: Title: Phone: 16.3 Supervising Station: This system, as s; - ifed herein, will be monitored according to all NFPA,sttaa\ndards cited herein. Sign `, • ! Printed name: Y� ` ..1441,Q t Date: k 1 1113 ri `� `i t. -1-7--t -1-7--t -9 13 Organization: � . ] � . Q . Title: �t�C�bE- �" lS3 L �� P hone: 9 Copyri p 0 2009 National Fire Protection Assodadm. This form tiny be coped for Individual use other than for resale. It tiny not be coped for aonnrerorel sate or dsafbrmon. 16. CERTIFICATIONS AND APPROVALS (continued) 16.4 Property or Owner Representative: I accept this system as having been installed and tested to its specifications and all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: 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: Organization: Title: Phone: Copyright 02009 National Fire Promotion Association. This form may be copied for individual use other than for resale. It may not be copied for cor mnerdal eale or r atilbrton. D�o \6 Id\ 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 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. 1. PROPERTY INFORMATION Name of property: 4 /; o �\ Address: Cq324( .�(p — " (6(7 Sp.s Ma �9a� IV�W J T Description of property: Oct.— Occupancy type: Name of property representative: Address: Phone: Fax: E -mail: Authority having jurisdiction over this property: Phone: Fax: E -mail: 2. INSTALLATION, SERVICE, AND TESTING CONTRACTOR INFORMATION Installation contractor for this equipment: 1►■'zj'vE D w :)42 -,S S s 3 �x ` - Address: \ 3 License or certification number: (C.$ Phone: Fax: E -mail: Service organization for this equipment: <A \€ - Address: License or certification number: Phone: Fax: E -mail: A contract for test and inspection in accordance with NFPA standards is in effect as of: Contracted testing company: 5 A t (� ( S 1 1 6 4 Address: Phone: Fax: E -mail: Contract expires: Contract number. Frequency of routine inspections: 3. DESCRIPTION OF SYSTEM OR SERVICE Erfire 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): 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 cominerdal sale or distribution. 3. DESCRIPTION OF SYSTEM OR SERVICE (continued) NFPA 72 edition: 2_0 Q Additional description of system(s): 3.1 Control Unit Manufacturer: \i Model number: C1 c,`j 0 3.2 Mass Notification System niSis 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 (WC) ❑ 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 e n 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: , (� . e. 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: E A copy of the site - specific software is stored on site. Location: . C • Q . 3.5 Off-Premises Signal Transmission ❑ This system does not have off - premises transmission. Name of organization receiving alarm signals with phone numbers: 'v Alarm: AO( A►.rr - L 4 V -Q AQ Phone: - 1 •2O o - t 1 N 1 Supervisory: • Phone: Trouble: t ' 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: Qit-o 10 lit-ot Stw (ZTV G__ If Chapter 27, specify the type of auxiliary alarm system: ❑ Local energy ❑ Shunt ❑ Wired ❑ Wireless Copyright 0 2009 National Fre Protection Association. This fare may be copied for individual use other than for resale. It may not be copied for commercial sale or dstributon. 4. CIRCUITS AND PATHWAYS 4.1 Signaling Line Pathways 4.1.1 Pathways Class Designations and Survivability Pathways class: 6 Survivability level: Quantity: (See NFPA 72, Sections 12.3 and 12.4) 4.1.2 Pathways Utilizing Two or More Media Quantity: Description: 4.1.3 Device Power Pathways 2 o 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: 4.2 Alarm Initiating Device Pathways 4.2.1 Pathways Class Designations and Survivability Pathways class: ?j Survivability level: Quantity: (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 o 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: Survivability level: " Quantity: Z (See NFPA 72, Sections 12.3 and 12.4) 4.3.2 Pathways Utilizing Two or More Media Quantity: Description: 4.3.3 Appliance Power Pathways 1 0 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 Copyright © 2009 National Fire Protection Association. This form may be copied for individual use other than for resale. It may not be coped for commercial sale or distribution. 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: 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: I Conventional: Other (specify): -- Type of coverage: ❑ Complete area [Partial area ❑ Nonrequired partial area Other (specify): Type of smoke detector sensing technology: ❑ Ionization hotoelectric ❑ Multicriteria ❑ Aspirating ❑ Beam Other (specify): // 5.2.2 Duct Smoke Detectors gr s 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 5.23 Radiant Energy (Flame) Detectors cli<system does not have radiant energy detectors. Type and number of devices: Addressable: Conventional: Other (specify): Type of coverage: 5.2.4 Gas Detectors system does not have gas detectors. Type of detector(s): Number of devices: Addressable: Conventional: Type of coverage: 5.2.5 Heat Detectors is 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 Copyright 42 2009 National Fre Protection Association. This forth 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: Z 5.2.7 Waterfow Alarm Devices ❑ This system does not have waterfiow alarm devices. Type and number of devices: Addressable: I. Conventional: Coded: Transmitter: 5.2.8 Alarm Verification is system does not incorporate alarm verification. Number of devices subject to alarm verification: 6/ Alarm verification set for seconds 5.2.9 Presignal I9's system does not incorporate pre- signal. Number of devices subject to presignal: `& Describe presignal functions: 5.2.10 Positive Alarm Sequence (PAS) 521<s system does not incorporate PAS. Describe PAS: 5.2.11 Other Initiating Devices Igl<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: 1 Coded: Transmitter: Other (specify): �� 6.2 Fire Pump Description and Supervisory Devices IE s 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) EKis 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 C7 This system does not have other supervisory devices. Describe: 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. 7. MONITORED SYSTEMS 7.1 Engine - Driven Generator is 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 lErs system does not monitor special hazard systems. Description of special hazard system(s): 7.3 Other Monitoring Systems is system does not monitor other systems. Description of special hazard system(s): 8. ANNUNCIATORS Ergis 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 s 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 0 This system does not have nonvoice notification appliances. Horns: /13) I With visible: 0 1 Bells: IN With visible: Chimes: With visible: \ Visible only: Other (describe): 93 Notification Appliance Power Extender Panels Igor nrs system does not have power extender panels. Quantity: Locations: 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 10. MASS NOTIFICATION CONTROLS, APPLIANCES, AND CIRCUITS is system does not have an MNS. 10.1 MNS Local Operating Consoles Location l: Location 2: Location 3: 10.2 High -Power Speaker Arrays Number of HPSA speaker initiation zones: Location l: 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: 103.1 Special Hazard Notification //his system does not have special suppression predischarge notification. e'1�4NS systems DO NOT override notification appliances required to provide special suppression predischarge notification. 11. TWO - WAY EMERGENCY COMMUNICATION SYSTEMS 11.1 Telephone System is 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-Way 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: 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) 113 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: 11A tor 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: 113 Other Two-Way Communication Systems Describe: 12. CONTROL FUNCTIONS This system activates the following control factions: ❑ 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 1"Ihis 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: c 2O 4 #'L Control panel amps: Overcurrent protection: Type: l . / (21�{'i Amps: Q Location (of primary supply panel board): 1 VA IA A ovlSk pAlu `�L )Q.\L_ — 1 Disconnecting means location: !! 13.1.2 Engine - Driven Generator is system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: Copyright O 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 s 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: . A C , P , Type: J L, A . Nominal voltage: 1 v U (.. Amp/hour rating: 3 Q .. Calculated capacity of batteries to drive the system: In standby mode (hours): .Z1—I � In alarm mode (minutes): �atteries are marked with date of manufacture IJBattery calculations are attached 13.2 In- Building Fire Emergency Voice Alarm Communication System or Mass Notification System SPISI; 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 Generators system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: 13.2.3 Uninterruptible Power System [3<v—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 Copyright 0 2009 National Fire Protection Association. This form may be copied to 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 is 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 9' 'his system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: 13.3.3 Uninterruptible Power System laTkis 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 conducting operational acceptance tests. This is a: ®'New system ❑ Modification to an existing system Permit number: The s p stem has been installed in accordance with the following requirements: (Note any or all that apply.) etv N FPA 72, Edition: d.r iQ 'NFP 70, National Electrical Code, Article 760, Edition: erv Manufacturer's published instructions Other (specify): System deviation ilrm referenced NFPA standards: Signed.` /J `ti ‘ Printed name: S(0 (' ( 1OVal}W' ate: I\ ? ‘2____ Organization: V .S . ,Q . Title: Ll \-54k Phone: q7 I- 22 1 s ` ° Copyright © 2009 National Are 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 ew 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 require nts of the following: ag 72, Edition: NFPA 70, National Electrical Code, Article 760, Edition: anufacturer's published instructions Other (specify): ❑ Individual devi. \ testin documentation [Inspection and Testing Form (Figure 14.6.2.4) is attached] Signed. ' I , Printed name: 3 tear tk 1/44v0 L Date: 1 \ 1 "[ 11- • Z- Organization: w , S , • P • Title: +(S3 Phone: (xi ∎ - 17- -1 - °%% 11 ';a 16. CERTIFICATIONS AND APPROVALS o 16.1 System Installation Contractor: . 5 S is ` This system, as s • = ed herein, has been installed and tested according to all NFPA standards cited herein. Signed: / i t ` Printed name: J t,an M v v'Vl1/4-(1,Q C 61 1 -Date: l l \Z 6 t - L Organization: iJ .5..v. f . Title: l ou.1- qt.-vs LE Phone: q-1 - 5(30 16.2 System Service Contractor: The undersigned has a service contract for this system in effect as of the date shown below. Signed: Printed name: Date: Organization: Title: Phone: 163 Supervising Station: This system, as s : ified herein, will be monitored according to all NFPA standards cited herein. Sign: • ' ', • •ii Printed name: c 44kO Date: 1 \ 1 (1-4 °— 0 , . F . P . Title: - - T “ . . ) . 4 - - t Lek Phone: 41 k • — CIA ' i3 6 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. 16. CERTIFICATIONS AND APPROVALS (continued) 16A Property or Owner Representative: I accept this system as having been installed and tested to its specifications and all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: 163 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: Organization: Title: Phone: CopyrlgM 0 2009 National Fre Protection Association. This form may be copied for Individual use other than for resale. It may not be copied for commerdal sale or distribution.