Report (49) cps 1---7.- .90 /
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 modem 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.
'?/30/17 N/A
Form Completion Date: Supplemental Pages Attached:
1. PROPERTY INFORMATION
Name of property: LINCOLN TOWER-10 FLR SUITE 1000
Address: 10260 SW GREENBURG RD,TIGARD,OR 97223
Description of property:
Name of property representative: SHORENSTEIN REALTY SERVICES
Address: 10220 SW GREENBURG RD.TIGARD,OR 97223
Phone: Fax: E-mail:
2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION
Installation contractor: CAPITOL ELECTRIC
Address: 11401 NE MARX ST PORTLAND,OR 97220
Phone: Fax: E-mail:
Service organization: SIMPLEXGRINNELL
Address: 6305 SW Rosewood St.,Lake Oswego.OR 97035
503-683-9000
Phone: Fax: E-mail:
Testing organization: N/A
Address:
Phone: Fax: E-mail:
Effective date for test and inspection contract:
Monitoring organization:
Address: N/A
Phone: Fax: E-mail:
Account number: Phone line 1: Phone line 2:
Means of transmission: SDACT
Entity to which alarms are retransmitted:nta Phone:
3. DOCUMENTATION
On-site location of the required record documents and site-specific software:FACP
4. DESCRIPTION OF SYSTEM OR SERVICE
This is a: New system Modification to existing system Permit number:
NFPA 72 edition: 2013
4.1 Control Unit
SIMPLEX 41000
Manufacturer:
Model number:
4.2 Software and Firmware
Fiware revision number: 12.05.07
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4.3 Alarm Verification This system does not incorporate alarm verification.
Number of devices subject to alarm verification: Alarm verification set for seconds
5. SYSTEM POWER
5.1 Control Unit
5.1.1 Primary Power
120 VAC 10A
branch circuit disconnecting means location: Number:
5.1.2 Secondary Power
Type of secondary power:
BATTERY
Location,if remote from the plant: FAC P
Calculated capacity of secondary power to drive the system:
24hrs 15mins
In standby mode(hours): In alarm mode(minutes):
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 0 0 B
Device Power 0 0 B
Initiating Device 0 0 B
Notification Appliance 0 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 0 ADDR- ALARM N/A
Smoke Detectors 0 ADDR. ALARM PHOTO
Duct Smoke Detectors ADDR. SUP ERV PHOTO
Heat Detectors 0 ADDR. ALARM THERMISTOR
Gas Detectors 0 ADDR. N/A N/A
Waterflow Switches 0 ADDR. ALARM N/A
Tamper Switches 0 ADDR. SUPERV. N/A
9. NOTIFICATION APPLIANCES
Type Quantity Description
Audible 0
Visible 7 STROBE
Combination Audible and Visible 0
10. SYSTEM CONTROL FUNCTIONS
Type Quantity
Hold-Open Door Releasing Devices 0
HVAC Shutdown 0
Fire/Smoke Dampers 0
Door Unlocking 0
Elevator Recall 0
Elevator Shunt Trip 0
11. INTERCONNECTED SYSTEMS
'---'--- ----...,-----'---------.-.d-- ----
12. CERTIFICATION AND APPROVALS
12.1 System Installation Contractor
This system as specified h n s been installed according to all NFPA standards cited herein.
Signed: 'Printed name:r.G�htl Date: �'
17
Organization: i �tcC t Title: 1{e K`t44 Phone: (p)) 311—iS$'7
12.2 System Operational Test
This system as specified herein has tested according to all NFPA standards cited herein.
BRIAN BOWLSBY 11/30/17
Signed: Brian Bow
lcby Printed name: Date:
Organization: SIMPLEXGRINNELL TECH REP 503-683-9000
Title: Phone:
12.3 Acceptance Test
Date and time of acceptance test:
Installing contractor representative:
Testing contractor representative:
Property representative:
AHJ representative:
Copyright 012012 National Fire Protection Association.This tore may be copied for individual use other than for resale.It may not be copied for commercial sale or distribution.