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Report (78) 4), 2(50 - OOD SYSTEM RECORD OF COMPLETION This form is to be completed by the system installation contractor at the time of system ce a?fi p roval? iā€” 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. Form Completion Date: 11/8/2017 Supplemental Pages Attached: N/A 1. PROPERTY INFORMATION Name of property: Madrona Recovery Address: 7000 SW Varns St, Tigard, OR 97223 Description of property: Care Facility Name of property representative: Micah Braithwaite Address: Phone: Fax: E-mail: 2. INSTALLATION, SERVICE,TESTING, AND MONITORING INFORMATION Installation contractor: Western States Fire Protection Address: 17500 SW 65Th Ave, Lake Oswego, OR 97035 Phone: 503-657-5155 Fax: E-mail: Service organization: Address: Phone: Fax: E-mail: Testing organization: Western States Fire Protection Address: 17500 SW 65Th Ave, Lake Oswego, OR 97035 Phone: 503-657-5155 Fax: E-mail: Effective date for test and inspection contract: Monitoring organization: Western Monitoring Address: Phone: 1877-367-9737 Fax: E-mail: Account number: AEO9 0417 Phone line 1: Phone line 2: Means of transmission: Radio Entity to which alarms are retransmitted: Central Station Phone: 1877-367-9737 3. DOCUMENTATION On-site location of the required record documents and site-specific software: Document box 4. DESCRIPTION OF SYSTEM OR SERVICE This is a: ®New system 0 Modification to existing system Permit number: NFPA 72 edition: 2014 4.1 Control Unit Manufacturer: Silent Knight Model number: 5820x1 4.2 Software and Firmware Firmware revision number: 4.3 Alarm Verification El This system does not incorporate alarm verification. Number of devices subject to alarm verification: 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. (p. 1 of 3) SYSTEM RECORD OF COMPLETION (continued) 5. SYSTEM POWER 5.1 Control Unit 5.1.1 Primary Power Input voltage of control panel: 120v Control panel amps: 6 Overcurrent protection: Type: Brkr Amps: 20 Branch circuit disconnecting means location: Data room Number: 5.1.2 Secondary Power Type of secondary power: SLA batteries 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 El This system does not have power extender panels o 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 B Device Power B Initiating Device B Notification Appliance B Other(specify): 7. REMOTE ANNUNCIATORS Type Location SK Front entry SK Front entry 8. INITIATING DEVICES Addressable or Type Quantity Conventional Alarm or Supervisory Sensing Technology Manual Pull Stations 2 Addressable Alarm Smoke Detectors 40 Addressable Alarm Photo Duct Smoke Detectors 0 Heat Detectors Gas Detectors Waterflow Switches 2 Tamper Switches 4 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. (p. 2 of 3) SYSTEM RECORD OF COMPLETION (continued) 9. NOTIFICATION APPLIANCES Type Quantity Description Audible Horns Visible Strobes Combination Audible and Visible H/S 10. SYSTEM CONTROL FUNCTIONS Type Quantity Hold-Open Door Releasing Devices HVAC Shutdown Fire/Smoke Dampers Door Unlocking 2 Elevator Recall Elevator Shunt Trip 11. INTERCONNECTED SYSTEMS O This system does not have interconnected systems. ā‘ Interconnected systems are listed on supplementary sheet 12. CERTIFICATION AND APPROVALS 12.1 System Installation Contractor This system as specified herein has been installed according to all NFPA standards cited herein. Signed: Printed name: Josh Long Date: 10/8/17 Organization: WSFP Title: A&D technician Phone: 503-502-0fi 12.2 System Operational Test This system as specified herein has tested according to all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: 12.3 Acceptance Test Date and time of acceptance test: Installing contractor representative: 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. ( . 3 of 3)