Report (66) ` - w �T�Rrt Y v RECORD OF COMPLETIONrp5 2�a "- 2_
s �.
ruff.,it to be completed by the s}s-tem installation contractor at the time of system acceptance and approval.
It shall be permitted to modify:thisfor m as needed to protide a more complete andfor clear record.
Insert NM to all unused lines.
Attach additional sheers data,or calculations as necessary to provide a complete record.
Form Completion Date: Supplemental Panes Attached:
i. PROPER T f INFORMATION
Name of property: - J� �l)4
Address: t 3-53-3 5‘,t3tog' ? ‘"1"-1 ci pritx, D
Description of proper —8voiS,4 e‘ .5
Name of property representative:
Address:
Phone: Fax: E-mail:
2. INSTALLATION,SE.VICE,TESTING,AND moixirromg INFORMATION
Installation canaactor. C-k Kei-t.) e\V c112-'L C'
Address: Up WA t')- 5.� N t►.C.4 pe.se, `)o t+.Tk n I)R a' 2-f}-3
Phone: Ill-L.D5—4A24D Far: E-mail:
Service oreanzation:
Address:
Phone: Far: E-mail:
Testing orgart-ation:
Address:
Phone: Fax: E-mail:
Erfectiv_date for test and inspection contract:
Monitoring organization:
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 {� c^�
On-sito location of the required record documents and site-sot:Zia software: Ps-1— V �c�r�
4. DESCRIPTION OF SYSTEM OR SERVICE
This is a: ❑New systemI,Modif cation to existing system Permit number:
NFPA 72 edition:
4.1 Control Unit \
Manufacturer. .� ,rte Model number: 5` c7 0 XL-
4.2 Software and Firmware
Firm ware revision number.
43 Alarm Verification 0 This system does not incorporate alarm verification.
Number of devices subject to alarm verification: Alarm verification set for seconds
Copriur+t 0 Mt?Heaanst are mats tics ids@on_his iconnow or:c pts.far individual use other tir t,mala 14 ney nal ba copied for coormri el We -d1%1).401:.
SYSTEM RECORD OF COMPLETION(continued)
5. SYSTEM POWER
5.1 Control Unit
5.I.1 Primary Power ^-� t�
Input voltage of control panel: I c�--D Ykt-c__ Control panel amps: 43'
Overcurrent protection: Type: �Q. G(hie-_ Amps: ---Q
Branch circuit disconnecting means location: porq r\ \ rc) Number: \ 2-
5.1.2 Secondary Power
Type of secondary power: )P'c 1, \Ly C j1., A 1 1-2
Location,if remote from the plant: /
Calculated capacity of secondary power to drive the system:
In standby mode(hours): In alarm mode(minutes): L2 7�V
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
\ I
Device Power
Initiating Device I
Notification Appliance I I
Other(specify):
7. REMOTE ANNUNCIATORS
Type t Location
8. INITIATING DEVICES
Addressable or
Tvpe Quantity Conventional Alarm or Supervisory Sensing Technology
Manual Pull Stations
Smoke Detectors
Duct Smoke Detectors I 1111111 I
Heat Detectors _'.-'�.
Gas Detectors vilnIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
Waterflow Switches 111.111111111111111�
Tamper Switches I
Copyright 02012 Nation&fire Protection Asso iaticn.This form may be copied for individual use other then for resale_it may not be copied for commercial sale or distribution.
1
SYSTEM RECORD OF COMPLETION(continued)
s NOTIFICATION APPLIANCES
Type I Quantity Description
Audible I
Visible I
Combination Audible and fusible j 1
i 0. SYSTEM CONTROL FUNCTIONS
Type Quantity
Hold-Open Door Releasing.Devices
HVAC Shutdown
Fire/Smoke Dampers
Door Unlocking
Elevator Recall
Elevator Shunt Trip
`l I. INTERCONNECTED SYSTEMS
0 This system does not have interconnected systems.
0 Interconnected systems are listed on supplementary sheet
12. CERTIFICATION AND APPROVALS
121 System Installation Contractor
'This system as specified herein has been installed according to all NFPA standards cited herein.
Signed: Printed name: $w T7 ae CYZ- Date: i//2_//pj
Organization: Goan-- / i N C.--- Title:, Phone: (So 3)"ye—2 72,8
12.2 System Operational Test
This system as specified herein has tested according to all NFPA standards cited herein.
Signed: Primed name: Date:
Organization: Tide: Phone:
12.3 Acceptance Test
Date and time of acceptance test
insttalling contractor representative:
Testing contractor representative:
Property representative:
AHl representative:
Ccpyrieht 3 2012 National Pre Prated/en AsscdaVol.This farm may be copied far inaitidu at Use cm3:umi fat rams.tt nay not u?cuptea for cumrnndal Sate Cr d Vr bjlicn.