Report (10) I rzc. ) 7-
SYSTEM RECORD OF COMPLETION -
This form is 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.
Form Completion Date: 2-17-2017 Supplemental Pages Attached: 0
1. PROPERTY INFORMATION
Name of property: FIVE LINCOLN CENTER
Address: 10200 SW GREENBURG RD PORTLAND,OR 97223-5510
Description of property: COMMERCIAL OFFICE BUILDING
Name of property representative: SHORENSTEIN
Address: SAME
Phone: Fax: E-mail:
2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION
Installation contractor: ON ELECTRIC GROUP
Address: 1709 SE 3RD AVE PORTLAND OREGON 97214-2507
Phone: Fax: E-mail:
Service organization:
Address:
Phone: Fax: E-mail:
Testing organization: SimplexGrinnell
Address: 6305 SW Rosewood St Lake Oswego,OR.97035
Phone: 503-683-9000 Fax: 503-675-6521 E-mail:
Effective date for test and inspection contract:
Monitoring organization:
Address:
Phone: Fax: E-mail:
Account number: Phone line 1: 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: WITH ENGINEERING
4. DESCRIPTION OF SYSTEM OR SERVICE
This is a: 0 New system ►Zi Modification to existing system Permit number:
NFPA 72 edition:
4.1 Control Unit
Manufacturer: SIMPLEX Model number: 4100ES
4.2 Software and Firmware
Firmware revision number: 1.02.01
4.3 Alarm Verification 0 This system does not incorporate alarm verification.
Number of devices subject to alarm verification: Alarm verification set for seconds
Copyright 0 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.
SYSTEM RECORD OF COMPLETION(continued)
6. SYSTEM POWER
5.1 Control Unit
5.1.1 Primary Power
Input voltage of control panel: 120 Control panel amps: 3 amps
Overcurrent protection: Type: breaker Amps: 20
Branch circuit disconnecting means location: 2L1 SECTION 2 Number: CKT-50
5.1.2 Secondary Power
Type of secondary power: Batteries
Location,if remote from the plant: in nac panel
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
Device Power
Initiating Device
Notification Appliance 1 B
Other(specify):
7. REMOTE ANNUNCIATORS
Type Location
8. INITIATING DEVICES
Addressable or
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 02012 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.
SYSTEM RECORD OF COMPLETION(continued)
9. NOTIFICATION APPLIANCES
Type Quantity Description
Audible - -
Visible 1 IN SUITE 250
Combination Audible and Visible 1 IN SUITE 250
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
This system as s iiiid herein h: been installed according to all NFPA standards cited herein.
Signed: Printed name: Ryan Anderson Date: ,~-1 2--/ 2
Organization: ON ELECTRIC GROUP Title: Phone: 503-849-2597
12.2 System Operational Test
This system as specified herein has tested according to all NFPA standards cited herein.
Signed: /` Printed name: Ryan Mendoza Date: 2-17-2017
APIV r
Organization. SimplexGrinnell Title: Tech Rep Phone: 503-683-9000
12.3 Acceptance Test
Date and time of acceptance test: 2-/i 1/2 C ( 7
Installing contractor representative: _„., _
Testing contractor representative: /P.- 1- c
Property representative:
ARI representative:
Copyright 02012 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.