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Report (146) Fc)sac - watO °WL c k Sh e 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,ori calculations as necessary to provide a complete record. Form Completion Date: —7— 13-1$ Supplemental Pages Attached: 1. PROPERTY INFORMATION l Name of property: Prh L4 Pay (a.+ Ati kovi ties+ Address: 1600) 500 c i♦C I S- 13gO 1 l5arc O 1 912-23 Description of property: aft' O :ce Space t n 5-54-o r 1 btu'Id;ni Name of property representative: Address: Phone: Fax: E-mail: 2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION n/ Installation contractor: Poi el+/4 Q A 4"0 rp Address: 603 L-tlke.vlew e v ft (o0 Lake AwA3o,0,E -7035 (p2. Phone: 503- 7-0100 Fax: E-mail: Service organization: lAje m 6474e 5 `f �eIte. Pro-f-ec f b v l Address: r7600 61$ ( 'Ave.5 41`Aye n i ©51Jep, ore g7O35 Phone: 5o3-(p57-5155 Fax: 6J` E-mail: Testing organization: (same a 5 above) Address: Phone: Fax: 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: 4. DESCRIPTION OF SYSTEM SERVICE This is a: 0 New system Modification to existing system Permit number: FP ,� Sig -0066o .2-D16 NFPA 72 edition: 4.1 Control Unit e-xid-in9 Manufacturer: $j i/e iF 1<n(5 i Model number: 8. L))(I— 4.2 Software and Firmware Firmware revision number: 4.3 Alarm Verification iThis 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) 5. SYSTEM POWER CJ �1 5.1 Control Unit (1‘54.1‘n� 5i/011—K14'i� 5 SXL ("fiA C .)-") 5.1.1 Primary Power Input voltage of control panel: 0-0-© Control panel amps: Overcurrent protection: Type: e( Amps: Branch circuit disconnecting means location: 3A A Number: i 7 5.1.2 Secondary Power Type of secondary power: Location,if remote from the plant: Calculated capacity of secondary power to drive the system: In standby mode(hours): f) .y In alarm mode(minutes): 5 5.2 Control Unit 1:3T is system does not have power extender panels Power extender panels are listed 6. CIRCUITS AND PATHWAYS Pathway Type Dual Media Pathway Separate Pathway Class Survivability Level Signaling Line Device Power Initiating Device Notification Appliance 5 C Other(specify): 7. REMOTE ANNUNCIATORS NA Type Location 8. INITIATING DEVICES NA 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©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) 9. NOTIFICATION APPLIANCES Type Quantity Description Audible Visible I yc4 5i1'OI Combination Audible and Visible // p-fCYvl Sea o- 10. SYSTEM CONTROL FUNCTIONS N/A ` 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 .s speciti ed herein has been installed according to all NFPA standards cited herein. Signed: 01/, Printed name: —a5on t)eyIrte Date: 7-/7--1 S Organiz. ion: j fr►-,Mon i+o rCorp, Title: TeolYIlc,a yl Phone: ,5.- o,00 12.2 System Operational Test This system as speci ed herein has tested according to all NFPA standards cited herein. Signed: of % Printed name: ` tpn vI n e Date: 7-1.2--/0 Organization: P la+Mot)l4O f Corp. Title: Teckvl ft f`ari Phone:5n3— /00 12.3 Acceptance Test / Date and time of acceptance test: _7-13-- /S 6 1004trvt Installing contractor representative: . (7A'5p(t[�yj rt l P Testing contractor representative: Property representative: AHJ 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.