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Report (59) 2c / &lc-7 SYSTEM RECORD OF COMPLETION �d ��� This.form is to he completed by the system installation contractor at the time of system acceptance and approval. It shall be permitted to modify this_forrn 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 protide a complete record. Form Completion Date: 5/11/16 Supplemental Pages Attached: 1. PROPERTY INFORMATION Name of property: ECM-Kindercare#301235 Address: 12658 SW North Dakota street Tigard, OR 97223 Description of property: Daycare Name of property representative: Address: Phone: Fax: E-mail: 2. INSTALLATION, SERVICE,TESTING, AND MONITORING INFORMATION Installation contractor: Fire Systems West Address: 600 SE Maritime Ave ste 300 Vancouver,WA 98661 Phone: 360-693-9906 Fax: 360-289-2208 E-mail: Service organization: Same Address: Phone: Fax: E-mail: Testing organization: Same Address: Phvnr: as: E-mail_ Effective date for test and inspection contract: Monitoring organization: Local System --Address: Phone: Fax: E-mail: Account number: Phone line I: Phone line 2: Means of transmission: Entity to which alarms are retransmitted: Phone: 3. DOCUMENTATION On-site location of the required record documents and site-specific software: 4. DESCRIPTION OF SYSTEM OR SERVICE This is a: ❑ New system ® Modification to existing system Permit number: FPS2016-00085 NEPA 72 edition: 13 4.1 Control Unit Manufacturer: Silent Knight Model number: SK-5208 4.2 Software and Firmware Firmware revision number: 4.3 Alarm Verification ®This system does not incorporate alarm verification. Number of devices subject to alarm verification: Alarm verification set for seconds Copyright©2012 National Fire Protection Association.This form may be copied for Individual use other than for resale.It may not be copied for commercial sale or distribution. (p. 1 of 3) SYSTEM RECORD OF COMPLETION (continued) 5. SYSTEM POWER 5.1 Control Unit 5.1.1 Primary Power Input voltage of control panel: 120 VAC Control panel amps: Osercurrent protection: Type: circuit breaker Amps: 20 Branch circuit disconnecting means location: Number: 5.1.2 Secondary Power Type of secondary power: Sealed Lead Acid Batteries Location,if remote from the plant: Calculated capacity of secondary power to drive the system: In standby mode(hours): 24 In alarm mode(minutes): 5 5.2 Control Unit ❑ This system does not have power extender panels ❑ Power extender panels are listed on supplementary sheet A 6. CIRCUITS AND PATHWAYS Pathway Type Dual Media Pathway Separate Pathway Class Survivability Level Signaling Line Des:ice Power niliuin Lt I)e\icc -�— Notification Appliance 1 B Other(specify): 7. REMOTE ANNUNCIATORS Type Location 8. INITIATING DEVICES Addressable olr Type Quantity Conventional Alarm or Supervisory Sensing Technology Manual Pull Stations Smoke Detectors Duct Smoke Detectors Heat Detectors Gas Detectors Waterflow Switches Tamper Switches Copyright©2012 National Fire Protection Association-This form may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution. (p. 2 of 3) SYSTEM RECORD OF COMPLETION (continued) 9. NOTIFICATION APPLIANCES Type Quantity Description Audible • Visible Combination Audible and Visible 1 Ceiling Mounted HornStrobe 10. SYSTEM CONTROL FUNCTIONS Type Quantity Hold-Open Door Releasing Devices HVAC Shutdown Fire/Smoke Dampers Door Unlocking Elevator Recall Elevator Shunt Trip 11. INTERCONNECTED SYSTEMS This system does not have interconnected systems. ❑ Interconnected systems are listed on supplementary sheet 12. CERTIFICATION AND APPROVALS 12.1 System Installation Contractor i his system❑s spec cd I •cin has been installed according to all NEPA standards cited herein. Signed: Printed name: Jason Babien Date: 5/11/16 Ot-g nit ttiont: Fire Systems West Title: Technician Phone: 360-771-2692 12.2 System Operational Test This system as sped-'d. erein has tested according to all NEPA standards cited herein. Signed: t Printed name: Jason Babien Date: 5/11/16 Organize 'on: Fire Systems West Title: Technician Phone: 360-771-2692 12.3 Acceptance Test r Date and time of acceptance test: e � / ,efr1 Installing contractor representative: Testing contractor representative Property representative: A1-1.1 representative: Copyright©2012 National Fire Protection Association.This form may be copied for individual use other than for resale_It may not be copied for commercial sale or distribution_ (p. 3 of 3)