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Report (162) k r� SYSTEM RECORD OF COMPLETION f9S 2 /f- ob kip 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: 8-23-18 Supplemental Pages Attached: 0 1. PROPERTY INFORMATION Name of property: Lincoln2 Kiewit Engineering Suite 350 Address: 10220 SW Greenburg RD Tigard OR 97223 Description of property: B Business Group Name of property representative: Shorenstein Reality Services Address: Same As Above 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: Same As Below Address: - Phone: - Fax: - E-mail: - Testing organization: Johnson Controls 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: Advantage Address: - Phone: - Fax: - E-mail: - Account number: 5220 Phone line 1: Radio Phone line 2: Radio Means of transmission: Radio Dialer Entity to which alarms are retransmitted: - Phone: 1-888-295-5298 3. DOCUMENTATION On-site location of the required record documents and site-specific FACP software: 4. DESCRIPTION OF SYSTEM OR SERVICE This is a: 0 New system Modification to existing system Permit number: Installer Holds Permit NFPA 72 edition: 2013 4.1 Control Unit Manufacturer: Simplex Model number: 41000 4.2 Software and Firmware Firmware revision number: 12.06.09 4.3 Alarm Verification ®This system does not incorporate alarm verification. Number of devices subject to alarm verification: 0 Alarm verification set for - seconds 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. Ir. ,rv�t 4 `i SYSTEM RECORD OF COMPLETION(continued) 5. SYSTEM POWER 5.1 Control Unit 5.1.1 Primary Power Input voltage of control panel: Existing/Unchanged Control panel amps: - Overcurrent protection: Type: - Amps: - Branch circuit disconnecting means location: - Number: - 5.1.2 Secondary Power Type of secondary power: Batteries/Generator/existing/unchanged Location,if remote from the plant: - 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 0 0 - Device Power 0 0 - Initiating Device 0 0 - Notification Appliance 0 1 B 1 Other(specify): 7. REMOTE ANNUNCIATORS Type Location Existing,LCD Lobby 8. INITIATING DEVICES Addressable or Type Quantity Conventional Alarm or Supervisory Sensing Technology Manual Pull Stations 0 - - - Smoke Detectors 0 - - - Duct Smoke Detectors 0 - - - • Heat Detectors 0 - - - Gas Detectors 0 - - - Waterflow Switches 0 - - - Tamper Switches 0 - - - 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. Cp. 2 of;` 114 • SYSTEM RECORD OF COMPLETION (continued) 9. NOTIFICATION APPLIANCES Type Quantity Description Audible 0 - Visible 4 New 1 Relocate Simplex 4906-9103 MC,White Combination Audible and Visible 4 Relocate Simplex 4906-9129 MC,White 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 ❑ This system does not have interconnected systems. ® Interconnected systems are listed on supplementary No sheet 12. CERTIFICATION AND APPROVALS 12.1 System Installation Contractor This system as.�. cified `rein has be taped according to all NFPA standards cited herein. Signed: / Printed name: t '-'(^ W e 3N-ltyt. Date: 8-23-18 Organization: Capitol Elect Title: gft-e^-wJ Phone: a (0'9) S I*$9s- 9' 12.2 System Operational Test This system ass c herein has tested according to all NFPA standards cited herein. Signed: Printed name: R Swatski Date: 8-23-18 Organization: Johnson Controls Title: Installer Phone: 503-683-9000 123 Acceptance Test Date and time of acceptance test: 8-24-18 0600 Installing contractor representative: Testing contractor representative: fit. .,- c Property representative: 4 AHJ representative: I// I 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.