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5 20/7440, cts1 0 Fire Alarm System - RECORD OF COMPLETION Reports of fire alarm testing and maintenance must be kept on site for a minimum of three years. All parts of the Owner Section MUST be completed. It is the owners responsibility to provide all required information to the service provider prior to the service/testing. The owners representative is also required to review all deficiencies found by the service provider upon completion of the service or testing. A. OWNER SECTION If additional space is needed for business names or suite BUILDING/PROPERTY INFORMATION numbers,please submit a separate list with this form. Name of Complex/Facility/Property: GOOD NEIGHBOR CENTER All Occupying Business Names: GOOD NEIGHBOR CENTER Street Address: 11130 SW GREENBURG ROAD All Suite Numbers: City: TIGARD State: OR Zip: Property Contact Person(s): JACK SCHWAS Title:MANAGER Authority to Approve Work: ®Yes 0 No 0 N/A Office Phone: (5o3 ) 443 - 6008 Mobile Phone: ( ) - Fax: (503 )254 -3004 BUILDING OWNER/RESPONSIBLE PARTY CONTACT INFORMATION Owner/Property Management Firm: SAME AS ABOVE Street Address: Suite Number(s): City: State: Zip: Responsible Contact: Title: Office Phone: ( ) - Mobile Phone: ( ) - Fax: ( ) - Report of Inspection,Testing&Maintenance Of Fire Alarm Systems Page 1 of 10 MONITORING AGENCY INFORMATION Name of Monitoring Agency: VERIFICATION CENTER Phone: ( 503 ) 223 - 7229 Contract Number: 148 Is Monitoring Agency Listed/Approved Central Station: ►7.1 Yes ❑ No UL or FM Central Certification Number: Monitoring Agency has Current Building Owner/Responsible Party Contact Information? 0 Yes ❑ No Date Contact Information Last Verified: 6-20-17 Y N N/A 1. Were all deficiencies reported at the last inspection corrected? 0 0 0 2. Was the owner(s)representative on site during the entirety of the alarm test? 0 0 ❑ 3. Are the tenants, occupancy types and hazards the same as reported on the last inspection? ❑ 0 0 4. Were any walls or partitions added or removed since the last inspection? 0 0 ❑ If any of the above questions were answered"no", please provide details of the conditions found and resulting actions taken: NOTE THIS IS JUST A FINAL RECORD OF COMPLETION FOR ADDING 1 SMOKE DETECTOR AND 1 NOTIFICTION APPLIANCE TO THE EXISTING FIRE PANEL 1 SMOKE DETECTOR ADDED TO ZONE 9 AND ZONE DESCRIPTOR UPDA l'ED SIGNALS VERIFIED WITH MONITORING 1 HORN/STROBE ADDED TO NAC OUTPUT 3 AMBIENT DBA PRIOR 46-68 DBA,IN ALARM STATE 98-102 DBA The alarm system owner(building/business owner)is responsible to maintain the alarms in working order. If the alarm system is out of service,an impairment coordinator must be named,and fire watch initiated. For impairments lasting longer than four hours,the Fire Marshal's Office must be notified. Report of Inspection,Testing&Maintenance Of Fire Alarm Systems Page 2 of 10 B. SERVICE PROVIDER SECTION Inspecting Firm (Contractor): UNITED FIRE HEALTH AND SAFETY Endorsement Number: Date of This Inspection: 6-20-17 Start Time of This Test: 11AM List ALL Inspector(s) Present During This Test:JOE PRICE,IAN JONES Date of Last Inspection: 12-3-15 Prior Inspector's Name(s): JOE PRICE Service Type: 0 Weekly 0 Monthly 0 Quarterly ❑ Semiannually ❑Annually 0 Other: FIRE FINAL Does Inspection Firm Conducting this Inspection Provide Runner Service? ❑Yes ® No If yes, please check signals runner service is provided for: 0 Alarm 0 Supervisory 0 Trouble Signals NOTIFICATIONS MADE PRIOR TO ANY TESTING Time Who Was Notified(Names) *Monitoring Agency 11AM OPERATOR *Building Management 11AM JACK SCHWAB Building Occupants 11AM STAFF Other(Specify) *AHJ Notified of Any Pre-Existing Impairments 0 0 Yes No (*ALL FIELDS MUST BE COMPLETED) SYSTEM&TESTING INFORMATION Fire Alarm System Performance Inspecting Agency Provides(check type, see NFPA 72, Table A.8.1, 2007 Edition): X❑ Protected Premises 0 Central Station Service ❑ Remote Supervising Station 0 Proprietary Supervising Station Please Answer ALL of the following questions (If any answers are"No",please provide details of conditions found and resulting actions taken in the comments field) Y N N/A Were the"Certificate of Completion"and"Record Drawings" identifying floor plan, device o ❑ locations, etc. available prior to inspection? Have all modifications made to the system since the last inspection been reviewed and documented in the Certificate of Completion on file? Does this report include the testing of ALL interconnected devices located on this property?(i.e. ® ❑ ❑ duct detectors, elevator recall functions, door interlocks, smoke control systems, etc.) Are spare keys to pull stations available? If yes, where: AT FACP ® ❑ ❑ Is the door to the room identified with a"FIRE ALARM CONTROL PANEL"sign? ® ❑ ❑ Are proper dedicated circuit(s) provided with circuit breaker lock(s)at the electrical panel? © ❑ ❑ Was the smoke entry into the sensing chamber of all smoke detectors verified(72-07, 10.4.2.2)? ® ❑ 0 Are smoke detector sensitivity testing records available and maintained using a proper testing schedule (72-07, 10.4.2.)? If sensitivity testing is required based on incomplete records or testing schedule,was it ❑ ❑ completed during this service? Comments: Report of Inspection,Testing&Maintenance Of Fire Alarm Systems Page 3 of 10 PROPERTY FIRE ALARM SYSTEM INFORMATION On-Site Location of Previous Test Reports: ON FILE Location of Record Drawings: UNKNOWN On-Site Location of Operation, Instruction and Maintenance Manuals: AT FACP Location of Main Fire Alarm Control Panel: MAIN ELECTRIC ROOM MAIN FIRE ALARM CONTROL PANEL(FACP) FACP Manufacturer: SILENT KNIGHT TRANSMISSION TYPE Model Number: 5208 0 McCulloh #Circuits or Addressable Points In Use: 9 0 Multiplex ❑X Digital Circuit Styles Installed : B 0 Reverse Priority Software Version: Firmware Version: ❑ RF ❑Other(Specify) Date Revised Software: Firmware: Person AND Agency who Developed Last Software Revision: Monitoring Agency Receives Proper Annunciation of Alarm, Supervisory and Trouble Signals: ®Yes 0 No Monitoring Agency Receives Correct Property Street Address and Zone Annunciation(s): ®Yes 0 No Does System have Emergency Voice Communication System? 0 Yes ►_i No Type Visual Functional Comments Control Unit(s) Interface Equipment El El Lamps/LEDS El 18l Fuses 181 D31 Primary Power Supply X❑ �� Trouble Signals El Disconnect Switches tEl Ground-Fault Monitoring El POWER SUPPLY A. Primary Main Power Nominal Voltage: 120 VAC Amps: 20 Overcurrent Protection: Type: THERMAL FUSE Amps: 3 Location (of Primary Supply Panel Board, Panel&Circuit Number): MAIN ELECTRIC ROOM PANEL Disconnecting Means Location: MAIN ELECTRIC ROOM PANEL B. Secondary Standby Duration of Full Alarm System Operation on Emergency Power During This Test: 5 minutes Report of Inspection,Testing&Maintenance Of Fire Alarm Systems Page 4 of 10 Batteries System Demand Design Battery Type(s) Amp Draw Amp Draw Amp Hour Test Description (*Semiannually**Monthly) in Standby in Alarm Available ❑Nickel-Cadmium* ®Sealed Lead-Acid* 7 LOAD TEST ❑ Dry Cell** ❑ Lead-Acid** O Other-Specify Date Batteries Manufactured & Expire: 2013 & 2018 Load Voltage Test Cl Yes ❑ No Manufacture Date Stamped on Batteries: ®Yes 0 No Discharge Test: e Yes 0 No Batteries Free of Corrosion/Leakage: IN Yes 0 NoCharger Test: ®Yes ❑ No Load Test Satisfactory: ®Yes 0 No Specific Gravity: 0 Yes ® No Number of Batteries On-Site: 2 Were ALL Batteries Inspected/Tested: ® Yes ❑ No Engine Driven Generator Engine-driven generator dedicated to fire alarm system(describe): Location of Fuel Storage: Quantity: ❑Gallons 0 Pounds Was the generator tested in accordance with NFPA 110? 0 Yes 0 No If yes, please provide report. C. Emergency or standby system used as a backup to primary power supply, instead of using a secondary power supply: O Emergency system described in NFPA 70, Article 700. ❑ Legally required standby described in NFPA 70, Article 701. ❑ Optional standby system described in NFPA 70, Article 702, which also meets the performance requirements of Article 700 or 701. Report of Inspection,Testing&Maintenance Of Fire Alarm Systems Page 5 of 10 ALARM NOTIFICATION DEVICES&CIRCUITS Number of Circuits in Use: 3 Style/Class: B Are All Circuits Monitored for Integrity: ® Yes ❑ No Satisfactory Type #Installed #Tested Yes No Deficiencies Noted Chimes 0 0 Electric Bells 0 0 Electric Horns 0 0 Combination Hom/Strobe 1 1 ® 0 Strobes 0 0 Speakers(incl. voice evac.) 0 0 Other(Specify) 0 0 (a) Do all devices produce a sound exceeding the prevailing equivalent sound level by 15 decibels, or exceed any maximum sound level with a duration of 30 seconds by 5 decibels minimum;whichever is louder? ® Yes 0 No (b) Do any sound levels exceed the 110 decibel maximum? 0 Yes ® No If Yes, where? (c) What type of device was used to measure sound level? SDI DB CHECKER (d) Were walls/partitions modified since prior test to affect notification distribution? 0 Yes ® No If Yes, where? (e) Are voice notification devices used? 0 Yes ►_I No If Yes, describe procedure used for audible clarity? ALARM INITIATING DEVICES Manual Pull Stations Number Installed: Number Tested: Circuit Style/Class: Additional Remarks: Satisfactory Yes No Deficiencies Noted Proper Annunciation at FACP&Remote Annunciator 0 0 Activates all assigned devices(bells, magnetic holds, ❑ ❑ etc.) Are all readily accessible 0 0 Proper TROUBLE notification at FACP once devices are ❑ ❑ rendered inoperable Report of Inspection,Testing&Maintenance Of Fire Alarm Systems Page 6 of 10 Waterfldw Switches Number Installed: Number Tested: Circuit Style/Class: Additional Remarks: Satisfactory Yes No Deficiencies Noted Proper Annunciation at FACP& Remote Annunciator 0 0 Activates all assigned devices(bells, magnetic holds, ❑ ❑ etc.) Are all readily accessible 0 0 Proper TROUBLE notification at FACP once devices are ❑ ❑ rendered inoperable Flow switch activates within 90 seconds after water flow 0 0 Tamper(Supervisory Alarms) Number Installed: Number Tested: Circuit Style/Class: Additional Remarks: Satisfactory Yes No Deficiencies Noted Proper Annunciation at FACP& Remote Annunciator ❑ 0 Activates all assigned devices(bells, magnetic holds, ❑ ❑ etc.) Proper TROUBLE notification at FACP once devices are ❑ ❑ rendered inoperable Flow switch activates within 90 seconds after water flow 0 0 Smoke Detectors Number Installed: 1 Number Tested: 1 Circuit Style/Class:B Additional Remarks: Satisfactory Yes No Deficiencies Noted Proper Annunciation at FACP& Remote Annunciator ® 0 Activates all assigned devices(bells, magnetic holds, ® ❑ etc.) Are all readily accessible tEl 0 Proper TROUBLE notification at FACP once devices are © ❑ rendered inoperable Were sensitivity readings performed?* ❑X ❑ MFG SELF TESTING *If sensitivity readings were not performed, please describe why. If they were performed,please submit form documenting the values. Report of Inspection,Testing&Maintenance Of Fire Alarm Systems Page 7 of 10 • Heat AND/OR Duct Detectors Number of Heats Installed: Duct: Number Tested: Duct Circuit Style/Class: Year Installed: Additional Remarks: Satisfactory Yes No Deficiencies Noted Proper Annunciation at FACP& Remote Annunciator 0 0 Activates all assigned devices(bells, magnetic holds, ❑ ❑ etc.) Are all readily accessible 0 0 Proper TROUBLE notification at FACP once devices are ❑ ❑ rendered inoperable Were heat tests performed? If yes, please describe how. 0 0 SUPERVISORY SIGNAL-INITIATING DEVICES Additional Remarks: Satisfactory Yes No Circuit ry et Deficiencies Noted Building Temperature 0 0 Site Water Temperature 0 0 Site Water Level 0 0 Fire Pump Power 0 0 Fire Pump Running 0 0 Fire Pump Auto Position 0 0 Fire Pump or Pump Controller Trouble 0 0 Generator in Auto Position 0 0 Switch Transfer 0 ❑ Generator Engine Running 0 0 Other: 0 0 Report of Inspection,Testing&Maintenance Of Fire Alarm Systems Page 8 of 10 ADDITIONAL EQUIPMENT Automatic Door Locks Number Installed: Number Tested: Additional Remarks: Satisfactory Yes No Deficiencies Noted All magnetic holds, timers, etc. operate properly 0 0 Other Interconnected Systems (Clean Agent, Fire Pump, Commercial Cooking Hood, Preaction, Deluge, etc.) Type(s) Installed: Included in this Inspection/Test? 0 Yes 0 No Satisfactory Yes No Deficiencies Noted Proper Annunciation at FACP& Remote Annunciator 0 0 Report of Inspection,Testing&Maintenance Of Fire Alarm Systems Page 9 of 10 DEFICIENCIES FOUND DURING INSPECTION (Please provide any further details relating to deficiencies found) DEFICIENCIES REPAIRED(Please provide details on all repairs made on-site during this inspection) COMMENTS(Please provide any further comments or issues of concern that may need follow up) NO a,THIS IS JUST A FINAL RECORD OF COMPLETION FOR ADDING 1 SMOKE DETECTOR AND 1 NO FRICTION APPLIANCE TO THE EXISTING FIRE PANEL 1 SMOKE DETECTOR ADDED TO ZONE 9 AND ZONE DESCRIPTOR UPDATED SIGNALS VERIFIED WITH MONITORING 1 HORN/STROBE ADDED TO NAC OUTPUT 3 AMBIENT DBA PRIOR 46-68 DBA,IN ALARM STATE 98-102 DBA DECLARATION Completed Date and Time of Test: 6-20-17 2:30PM Fire alarm system restored to service without troubles or faults? ® Yes 0 No If No, document conditions. I JOE PRICE , certify that I tested the fire alarm system at the address identified in this test report, documented the conditions found during the inspection and have listed all deficiencies that were either corrected prior to leaving or require additional follow up. Any deviation or items identified by NFPA 72 to be tested that were not by nature of the site conditions or service contract have been identified on this report. Signature 1 Date: 6-20-17 2:30PM t • Report of Inspection,Testing&Maintenance Of Fire Alarm Systems Page 10 of 10