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I 10/2/2017 Detailed Account History 1 k.3 S (.2ctijt ` ' genc,Ytri .v_.,.e _.... y:sit Search A Home V ril Help/U.-Vote ®Contact Us ot logoff Attmer# Ra3810 The Datertime field represents the moment the action being taken was completed(End Time).To see both the Start Two and End Time of an action,please click here. Activities For Account R93810(912112017 00:00-9/21/2017 24:00) TTSD-TIGARD ELEMENTARY-FIRE 12855 SW GRANT ST TIGARD,OR 97223-0000 (503)431-4017 SlgL Daterme Condition(AIM Account) _ I Descnptlon L y�Sernce/CommentL_.s Entity Culled L Operator L 09/21/1718 37 38(P) I AUTO TEST SIGNAL DAILY TESTL_ automatic test RD E602000000 (n/a) 25 .A__ L_ 09/21/17 16:37:39(P) L FAILURE TO RESTORE _ L L logOnly signal RD P3S4000915 (n/a) I 25 L'... 0921/17 16:37:40(P) I . . _ FAILURE TO RESTORE _ IogOnly signal RD P140000008 •L ON2 �L5 69/21/17,16:37:41(P) ` FAILURE TO RESTORE _. L_.._ ,. ._ _____A____ IogOnlygn sial RD P140000008 (n/a)__ 25 -L 092FAILURE TO RESTORE L 1/17 16 37 42(P) I __L logOnly signal RD P370000001 L (n/a) I 25 77L,__09/21/17,16:37:43(p),_. I FAILURE TO RESTORE I __ L IogOnlysignal RD P370000001 _ (n/a),_____11_____2_5 �L 09/21/17 19:34:00(P) L_ XX TEST AUTHORIZED BY(In test) I EXP.09/21/17 21:34:00(P) L SCOTT DULANE I R93810 L NT L 09/21/17_19:34:01(P),_ L XX TEST AUTHORIZED BY(in test)__ I _ EXP 0921/17 21:34:00(P) _ START UP ` __ (n/a) L NT I 09/21/1719:35.29(P) L __ SPECIAL CONDITION L AL CO NAME L testing call RD EI40000008 (n/a) L 25 �I__09/21/17,19:35:35(P)____ TROUBLE ALARM L._ 11,_ lasting call RD E370000001 l (n/a) ___ L 25 E-7-10921/17 19:35:45(P)_, _RESTORE_________ I_ _ LOG ONLY L testing call RD R35400C915 I (n/a) 25 I_-[ 09/21/17 19:3546(p)_ _ RESTORE ,I _LOG ONLY ..._.,.I testing call RD E3050 ___00802 (n/a) ,I. ._.___25 I_—,.L 0921/17 19:35:47(P) L RESTORE IL__ LOG ONLY - L testing call RD E30500C902 I (n/a) I 25 I .08/21/1719:35:48(P). ,[1______ FAILURE TO RESTORE .___ _ •___j______.testing call,RD P140000008_ __Orn..........?...5 [ L 21 09 /17 1935.49(P) FAILURE TO RESTORE _ L ____JL testing call 40 RD P1000008_ L___ (n/a) _ ` 25 09/21/17 19:35:53(P) IFAILURE TO RESTORE L _ L_ testing call RD P370000001 __L (n/a) L_ 25 F-17—' 1, 09/21/17 19:35:54(P) L FAILURE TO RESTORE _ I testing call RD P370000001 L__. (n/a) 1 25 L 09/21/17 19 35 56(P) .L _ AUTO TEST SIGNAL _. ,1_,,,,. ._DAILY TEST testing ca11RD E6132000000 L (n/a) L 25 ' 09/21/17 19:35:57(P) AUTO TEST SIGNAL _L— DAILY TEST L testing call RD E602000000 (n/a) 11,,_ 2S I_—••.,I... 59/21/1719:35:59(P)__ .I _. FAILURE TO RESTORE __ L_._ ....______ _.._____ .. ____L testing call RD PI40000008.,. ,L__ (n/a)__,...... .L 25 l—L 09/21/17_19:36:90(P) L __ FAILURE TO RESTORE ____L___ I� testing call RD_P37o00C001 I (n/a) _L___35_ 0921/17,19:,58,62(P)_ __A____...._ SPECIAL CONDITION ._. L AL CO NAME_ _______1_, testing call RD E140000008 '1.__ (n/a) ._ L 25 H-71IL _09/21/17,19:58:03(P) L __ SPECIAL CONDITION AL CC NAME _____L__testing call RD EI40000008 I (n/a) 25 ETA ,,,,,69/21/17,1658:31(P) I _ COMMUNICATION FAILED L COMMUNICATION FAILURE L __testing call RD E35400C915 ,I, (n/a) L 25 I—L 09/21/1719:58:32(P)___ ..COMMUNICATION FAILED I .. COMMUNICATION FAILURE _A______._testing call RD E354000815 L (n/a)_ LLL 25 I_-I 0921/1719:58:33(P) ,L RESTORE__ ,1 LOG______ LOG ONLY_____.. _____L.. _testing call RD E30500C901___ L. (n/a).______ L.,__..25 *I 'L 0921/17 19:58:34(P) iL_ __ AUTO TEST SIGNAL DAILY TEST testing call RD E602000000 L_ (n/a) _L 25 I_—.I 09/21/17 19:08 35(P) __ ......_ AUTO TEST SIGNAL _ __L___, .. _DAILY TEST ,_11,__________ , stin teg call RD E602000000 ,L (n/a) _25 _,25 FAI_L__UREL___ ____ __,. ... . [—L 09/21/17 19:58:50(P) L RESTORE L LOG ONLY L �L L .— testing call RD R140000008 (n/a) 25 FT-I__0921(17 2001:26(P)_ I ____ _RESTORE __._ __1_,_., _____,....9_9.ONLY._.__ .... L ....__testing call RD,R...39..9.9915 L,_____ (n/a)._._.. __.2 I_—I 0921/17 20:01 31(P). I __ ___ RESTORE_ _ _ __ LOG ONLY _ I testing tali RD E30500C901 ,I _ (n/a) __ I 09/21/17 20:01:32(P) L_ AUTO TEST SIGNAL ( DAILY TEST __Th testing call RD E602000000 L (n/a) L 25 �hL 0921/17 20:01:33(P)__ AUTO TEST SIGNAL L__ DAILY TEST L tengsticat RD E602000000_ L_ (n/a) L _p_ ._____11-7.09/21/17 20:54:02(P) L SPECIAL CONDITION L ,_AL CO NAME _ I _testing call RD E140000008 I_. (n/a)_.. L 25 _E71,____99./21111.7 59/21/1720:54:03(P) SPECIAL CONDITION .____11.1.1.1.1___ILIT____A17.9.9.__1`.1AME L testing call RD E140000008 25 -I 0921/17 20 14 59(P) L _ RESTORE _ (.,. _LOG ONLY___ __L testing call RD R140000008 (n/a) .. L _25 ETA_ 09/21/17 20:15:00(P) [ _ RESTORE I _ LOG ONLY _,. I testing call RD R140000008 L (n/a) I 25 _ 0921/17 20:16:51(p) I SPECIAL CONDITION L AL CO NAME L testing call RD E140000008 L (n/a) L _25 �ISPECIAL CONDITION AL CO NAMEtesting call RD Et40000008 I (n/a) _ A____?___09/21/17 20 16 52(P)_ __ .. __ .,L._ ._._ .. ._ _. L _ I_—I 0921/17 20:18:17(P), L RESTORE LOG ONLY testing call RD R140000008 I (n/a) I 25 I_-L09/21/17 20:19:28(P)_ L .. SPECIAL CONDITION _____A___.__.._ALCO.,NAME_ . ____L____,.__testing call RD E140009008. I_____(n/,a),._____ L .__ L25 TA 0921/1720203 ,.L8(P) COMMUNICATION FAILED ... .. . I . COMMUNICATION FAILURE.., uL ..__testing call RD E35400C915 .L (n/a) _,,1___,,25_, 0921/17 20:20:39(P)_ 11____ - RESTORE__________ ____Ii LOG ONLY testing call RD E30500C902 (n/a) L 25 [L 0921/17 20 20 40(F) I TROUBLE ALARM L_ testing call RD E307000801_ L_ (n/a)_ I 25 I—TL 0921/17 20:26:48(p) I __ RESTORE L _ ._.LOG ONLY ..._,. L testing call RD R35400C915 L (n/a) -I 25 L' L 09/21/17 20 20:49(P) L RESTORE L____. LOG ONLY L testing call RD R307000800 L (n/a) L 25 [ I 0921/1720:20:50(P) ,L ___._ _,. RESTORE ILOG ONLY L testing call RDR30700C800 _.._ (n/a)...._. ,._..25 I L 0921/17 20:21:04(P) L ,... AUTO TEST SIGNAL .... -L DAILY TEST .,, L _testing call RD E60200000.0 I (n/a) L 25 L L_ 09/21/17 20:30:00(P) I XX TEST AUTHORIZED BY(in test) L EXP.09/21/1722:30.50(P) I SCOTT DULANE _ L R93810 Ly NT I=I 0921/17,29.391T(1!), L XX TEST AUTHORIZED BY(n test) I EXP 0921/17 22 30:00(P) _____11. REPLACING BOARD .,_ (n/a) _ _NT 09/21/17 21:07:43(P) 1L RESTORE _ L__ _ LOG ONLY testing cat RD E30500C902 I (n/a) 25 I—I 69/21/17,21:07:44(P), L FAILURE TO RESTORE . _ •. _ ,_ ___ L testing call RD P140000001 L (n/a) __25____ 7. 5 ^I 69/21/1721:07:45(P) I AUTO TEST SIGNAL ___ ___1_ „DAILY TEST. ___A___ _lasting call RD E602000000 I (n/a) .. L __25 I—I 0921/17 21:07:49(P)____ L FAILURE TO RESTORE L. ________A_ testing call RD P140000002 L (n/a) I .25 0921/17 21 07 55(F) L _ FAILURE TO RESTORE ____. L _ ____ _____ ___ I _ testing call RD PI40000003 I (n/a)_ I __ L 1Z1:07:51(P) FAILURE TO RESTORE ... 25 •'••..I 0921/17 ,L A___-____A 09/21/17 21:07:52(P) L _ FAILURE TO RESTORE L _ ,L testing call RD P140000004 L (n/a) L_ 25 I_ •..I 09/21/1721:07:53(P) I FAILURE TO RESTORE _ __testing call,RD P140000004 L.____(../.)__ 1.___25 0921/17 21 07 54(P) I FAILURE TO RESTORE ___ L L testing call RD P140000005 I (n/a) L 25 1—L 09/21/17 21:07:55(P) L_ T FAILURE TO RESTORE _L— I testing call RD P140000006 L (n/a)___ L 25 _ 'F.'L 0921/17 21 07 56(P_ I _ - FAILURE TO RESTORE _ u __ __ ___ .,__,_ I testing calRD P140000005 L. (na _ L ......3__ __ _ ____ L__ .. .... I ..testing call RD P14000e007 ,L._ (n/a)_ .L __25 �L 0921/17 21:07:57(p), �L _________,FAILURE TO RESTORE __ ...... ___ testing call RD P140000006 I (n/a) _ L_ 25 L' L 0821/17 21:07:58(P) L FAILURE TO RESTORE25 _____I_______testing call RD P140000008 L. (n/a),. L FTI 09/21/17,21:08:00(P) 1 FAILURE TO RESTORE L testing call RD PI4000c001 -L (n/a) I 25 -I 09/21/17 21:08,61(P) uL FAILURE TO RESTORE L. _.._I_ ...testing call RD40 P1000001_ I (n/a) 125 0921/17 21 08 02(P) ( FAILURE TO RESTORE I__ ,,,_ __ _ L _testing call RD P140000007 L (n/a)__ I _.25 �L - P __ __,. (n/a)__ ,I _25 09/21117_21 08 03(P) I FAILURE TO RESTORE I _ _ __ I testing call.RD P140000002 L L._I 09/21/17 21:08:04(P) I . FAILURE TO RESTORE _l_ . ___ ___ __ L __testing call RD P140000008 I. (n/a). 125 _ _95/21/17210805(P) .L ___ wL__ ___ . . ___ __ ..1...______.............RD P140000003 .L_. (n/a)___. ._...]___2..L. ETAFAILURE TO RESTORE l—L 09/21/17,21:08:06(P)_ L FAILURE TO RESTORE L I testing call RD P140000004 L (n/a) 25 L -- -. _ testing call RD P140000005 I.__ (n/a) I... __25 I 0821/17 21:08:07(P) L FAILURE TO RESTORE L__ L https://future.wwz.com/secure!/em24accreport.asp 1/2 •10/2/2017 Detailed Account History I •_ I_-. 09/21/17 21:08:08(P) FAILURE TO RESTORE L .. I .. ,testing call RD P140000006 ,. L 09/21/17 21 08:09(P) I ---, FAILURE TO RESTORE---- I [ (n/a) 25 -----.-- L _ ____ testing call RD P140000006 I (n/a) L 25 � I FAILURE TO RESTORE �— 09/21/17 21 08 10(P) ` -,"- I testing call RD P140000008 (n/a) I 25 �1 09/21/17 21:08:26(P) 11 SPECIAL CONDITION [ AL CO NAME testing call RD E140000008 JI (n/a) I 25 L•- 1 0921/17 21:08:36(P) I COMMUNICATION FAILED COMMUNICATION FAILURE 1 testing call RD E35400C915 ,.. (n/a) ,,I 25 7-1 09/21/17 21.08:37(P) I COMMUNICATION FAILED".. !L COMMUNICATION FAILURE ----- 1 testing call RD E35400C915 I (n/a) l 25 7-1 -09/21/17 21:08:38(P) ` .-"-. RESTORE I_ LOG ONLY I .-. testing call RD E30500C901 1 (n/a) -- 25 ----"-"": [—•—.40921/17 21.08:39(P) I RESTORE 1 LOG ONLY 1 testing call RD E30500C901 L (n/a) 1 25 L • t 0921/17 21:08:40(P) I FAILURE TO RESTORE I-- I testing call RD P140000008 (n/a) L•- [ 09/21/17 21:08:41(P) FAILURE TO RESTORE L "" ------ R 0 _ 25 .I _ testing call RD P740000008 (n/a) 25 �i .0921/17 21:08:51(P) RESTORE LOG ONLY 1 testing call RD R35400C915 (n/a) 25 0921/17 21:08:52(P) RESTORE - --"_-- I - -- "---. "" -_-.. LOG ONLY _ testing call RD R35400C915 (n/a) 25 09/21/172108.53(P) -- AUTO TEST SIGNAL �- ..09/21/17 21 08:54(P) L 'l_ .__-_ DAILY TEST — L testing call RD E602000000 L (n/a) L 25 • I __FAILURE TO RESTORE1 :I testing call RD P140000008 25 [I 09/21/17 21:08:55(P) I "" FAILURE TO RESTORE 1"" I testing call RD P140000008 I (n/a) 1 25 L • I 09/21/17 21:08:56(P) L__ _,_ RESTORE _-- ONLY _ "_- L I ----- -,_, .L LOG testing call RD R140000008 (n/a) 25 1-7-' 1 0921/17210857(P) -,.--- AUTO TEST SIGNAL .1-_ . DAILY TEST I .-. testing call RD E6020000001" 09/21/17 21:11:25(P) [ TROUBLE ALARM testing call RD E307000801 (n/a) "-- 25 I _µ I I- [-L 0921/17 21:11:26(P) TROUBLE ALARM (n/a) 25 I testing call RD E307000801 (n/a) 2$ II I. • I 09/21/17 21:14:14(P) ` RESTORE I LOG ONLY I testing call RD R307000800 I (n/a) _25 (— 09/21/17 21:14:51(P) I SPECIAL CONDITION _ [ AL CO NAMEI testing call RD E140000008 (n/a) _ 25 09/21/17 21:14:52(P) I SPECIAL CONDITION --- R"" -- - AL CO NAME testing call RD E740O00008 (n/a) 25 • 0921/17 21:17:43(P) -- L _ SPECIAL CONDITION AL CO.NAME _testing call RD E140000008 (n/a) 25 I—I 0921/17 21:17:58(P) I - ------ - i � RESTORE I LOG ONLY L testing call RD R140000008 _ (n/a) I 25 r—I 09/21/17 21:18:00(P) I ---""" RESTORE LOG ONLY I testing call RD E30500C901 I. (n/a) 1 25 I I 0921/17 21:18:01(P) I AUTO TEST SIGNAL I DAILY TEST I testing call RD E602S00000 (n/a) 1 -,_25 *I 09/21/17 21:20:01(P) I PRIMARY PHONE FAIL m.. I PRIMARY PHONE FAIL I testing call RD E351000001 TM (n/a) _25 jllL 09/21/17 2120:10(P) I SECONDARY PHONE FAIL SECONDARY PHONE FAIL L testing call RD E352500002 �I (n/a) � 25 -_I0921/1721:20:11(P) I SECONDARY PHONE FAIL SECONDARY PHONE FAIL I (-- I ---"-- - �-- ---- - ------ L .__-_testing callRDE35200C002 L (n/a) I 25 L --_I 0921/17 21:30:25(P) I SPECIAL CONDITION AL.CO.NAME .L-_ __. I testing call RD E140000008 (n/a) 25 1—^1 09/21/17 21:31:26(P) I _ SPECIAL CONDITION AL CO NAME l _., testing call RD E1400SC008 (n/a) 25 L l 09/21/17 21:31:38(P) RESTORE -"--- --- ""--�LOG ONLY R -I- F ""_._- IL--j --- - 1 -- -- L"""" -_—" testing call RD R140000008 I. (n/a) 25 25 F-7-1 0921/17 21:31:42(P) RESTORE I LOG ONLY I testing call RD E30505C901 1 —I 09/21/17 21:31A3(P) I - AUTO TEST SIGNAL l.. DAILY TEST L _teshng call RD E602000000 ,L (n/a) 25 7-1 L 0921/17 21:31A4(P) I _ AUTO TEST SIGNAL I" DAILY TEST L testing call RD E602000000 L 25 L 09/21/17 21:35:11(P) RESTORE _ I LOG ONLY L testing call RD R351000001 I (n/) 1 25 09/21/17 21:35.12(P) I -"_ RESTORE -.__--" '_._ 1 L I ` LOG ONLY testing call RD R351000001 I (n/a) 25 ` 1 09/21/17 21:35:24(P) I ---.- TROUBLE ALARM L. . _ --- E4 -I 0921- - - ---. -- -. -- ,teshng call RD E32034C004 I---- (n/a) " -25 /17 21 35 25(P) I. - RESTORE L LOG ONLY L testing call RD R32034C004 (n/a) 25 I—I 0921/17 21:35:34(P) I .--"-. FIRE ALARM AUTH.NAME -- - L_ ( I -- - ----" _- I _ ,. "_. I testing call RD E11533C013 i (n/a) 25 -I_ 09/21/17 21:35:35(P) L.-_..,,._- FIRE ALARM ,-. ®�_V4LL AUTH.NAME .__,_,..,.�_, testing call RD E11533C013 L (n/a) I ---I 0921/17 21-35:36(P) RESTORE i___25 I a LOG ONLY ( testing call RD R11533C013 (n/) II 25 -1 0921/17213537(P). I RESTORE -_ -_... l _-- -_" I _ LOG ONLY I testing call RD R77533C013 (n/a) 25 L' I 09/21/17 21:35.38(P) I RESTORE L_ LOG ONLY L testing call RD R11533C013 1 (n/a) 25 rn_ 0921/17 21:35:48(P) I RESTORE I • 09/21/17 21:36:02(P) i I_"__ LOG ONLY -"""-- I testing", call RD R351000001 I (n/a)_-.- -25 I I _-- TROUBLE ALARM -._- "-_ .__"I testing call RD E32034C004 L""-- (n/a)"-- I -.._25 -I 0921/17 21:36:03(P) TROUBLE ALARM - - -- testing call RD E32034C004 L (n/a) I 25 0921/17 21:36:04(P) _..._ RESTORE LOG ONLY I testing call RD R32034C004 1_ (n/a) 1 25 C—I 09/21/17 21:36:09(P) I FIRE ALARM I AUTH.NAME -___ _ I testing call RD E11533C013 1...- (n/a) ... I --25 , -[ 09/21/17 21:36:10(P) 1 FIRE ALARM I — AUTH.NAME I "testing call RD E11533C013 _ (n/a) 25 - 0921/17 21:36:11(P) I .-. --- RESTORE LOG ONLY testing call RD R11533C013 L- (n/a) -257-1 ---- 09/21/17 21:36:12(P) I __----__" RESTORE I.- ""_ -_- 1 --- I - LOG ONLY testing call RD R11533C013 I (n/a) 25 t • I. 0921/17 21:38:42(P) ---"T _. --- -- TROUBLE ALARM testing call RD E32034C004 (n/a) 25 L • L 0921/17 21:38:43(P) I TROUBLE ALARM I"- I - --- L__"" testing call RD E32034C004 (n/a) 25 L_ I 0921/1721:38.52(P) RESTORE I t_ L _ ,L LOG ONLY I testing call RD R32034C004 (n/a) 2$ C�L 0921/17 21:42:06(P) I RESTORE LOG ONLYL 1...__" ""_ testing call RD R352000002 -L 0921/1721:42:07(P) RESTORE .--._— ---- _ I"""_ ..__LOG ONLY ".-.----I_ testing call RD R352000002I (n/a) I 25 p--L.,_0921/17 21:42:58(P) L FIRE ALARM I AUTH.NAME [ testing call RD E115330513 I - (n/a) F---H. 09/21/17 25 L 09/21/17 21:43:20(P) L - RESTORE LOG ONLY I testing call R D R11533C013 ';I""""_ (n/a)_.....""" ,L 25 Total activities:132(*Total signals received:128) https://future.wwz.com/secure1/em24accreportasp 2/2 FIRE ALARM AND EMERGENCY COMMUNICATION SYSTEM RECORD OF COMPLETION 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. 1. PROPERTY INFORMATION Name of property: Charles F Tigard Address: 12855 SW Grant Ave Description of property: School Occupancy type: E,B Name of property representative: Philip Wentz Address: 6960 SW Sandburg St Tigard,OR 97223 Phone: Fax: E-mail: pwentz@ttsd.kl2.or.us Authority having jurisdiction over this property: Phone: Fax: E-mail: 2. INSTALLATION, SERVICE,AND TESTING CONTRACTOR INFORMATION Installation contractor for this equipment: Performance Systems Address: 7324 SW Durham Rd Portland,Ore 97224 License or certification number: Phone: 503-641-2222 Fax: 503-641-1464 E-mail: psintegrated.com Service organization for this equipment: Performance Systems Address: 7324 Durham Rd. Portland Or 97224 License or certification number: Phone: 503-641-2222 Fax: 503-641-1464 E-mail: psintegrated.com A contract for test and inspection in accordance with NFPA standards is in effect as of: Contracted testing company: Performance systems Address: 7324 Durham Rd Porland Or 97224 Phone: 503-641-2222 Fax: 503-641-1464 E-mail: Psintegrated.com Contract expires: Contract number: Frequency of routine inspections: 3. DESCRIPTION OF SYSTEM OR SERVICE ®Fire alarm system(nonvoice) ❑Fire alarm with in-building fire emergency voice alarm communication system(EVACS) ❑Mass notification system(MNS) ❑Combination system,with the following components: ❑Fire alarm ❑EVACS ❑MNS ®Two-way,in-building,emergency communication system ❑Other(specify): NFPA 72, Fig. 10.18.2,1.1 (p. 1 of 12) Copyright©2009 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. DESCRIPTION OF SYSTEM OR SERVICE (continued) NFPA 72 edition: Additional description of system(s): 3.1 Control Unit Manufacturer: Silent Knight Model number: IFP1000 3.2 Mass Notification System ®This system does not incorporate an MNS 3.2.1 System Type: ❑In-building MNS—combination ❑In-building MNS—stand-alone ❑Wide-area MNS ❑Distributed recipient MNS ❑Other(specify): 3.2.2 System Features: ❑Combination fire alarm/MNS ❑MNS autonomous control unit ❑Wide-area MNS to regional national alerting interface ❑Local operating console(LOC) 0 Direct recipient MNS(DRMNS) 0 Wide-area MNS to DRMNS interface ❑Wide-area MNS to high-power speaker array(HPSA)interface ❑In-building MNS to wide-area MNS interface ❑Other(specify): 3.3 System Documentation ®An owner's manual,a copy of the manufacturer's instructions,a written sequence of operation,and a copy of the numbered record drawings are stored on site. Location: AT FACP 3.4 System Software ❑This system does not have alterable site-specific software. Operating system(executive)software revision level: Site-specific software revision date: Revision completed by: ❑A copy of the site-specific software is stored on site. Location: 3.5 Off-Premises Signal Transmission ❑This system does not have off-premises transmission. Name of organization receiving alarm signals with phone numbers: Alarm: Emergency 24 Phone: 1-800-444-3624 Supervisory: Emergency 24 Phone: 1-800-444-3624 Trouble: Emergency 24 Phone: 1-800-444-3624 Entity to which alarms are retransmitted: Phone: Method of retransmission: AES Radio If Chapter 26,specify the means of transmission from the protected premises to the supervising station: If Chapter 27,specify the type of auxiliary alarm system: ❑Local energy ❑ Shunt ❑Wired ❑Wireless NFPA 72, Fig. 10.18.2.1.1 (p. 2 of 12) Copyright©2009 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. 4. CIRCUITS AND PATHWAYS 4.1 Signaling Line Pathways 4.1.1 Pathways Class Designations and Survivability Pathways class: B Survivability level: 1 Quantity: 2 (See NFPA 72,Sections 12.3 and 12.4) 4.1.2 Pathways Utilizing Two or More Media Quantity: Description: 4.1.3 Device Power Pathways ®No separate power pathways from the signaling line pathway ❑Power pathways are separate but of the same pathway classification as the signaling line pathway ❑Power pathways are separate and different classification from the signaling line pathway 4.1.4 Isolation Modules Quantity: 4.2 Alarm Initiating Device Pathways 4.2.1 Pathways Class Designations and Survivability Pathways class: Survivability level: Quantity: (See NFPA 72,Sections 12.3 and 12.4) 4.2.2 Pathways Utilizing Two or More Media Quantity: Description: 4.2.3 Device Power Pathways ®No separate power pathways from the initiating device pathway ❑Power pathways are separate but of the same pathway classification as the initiating device pathway ❑Power pathways are separate and different classification from the initiating device pathway 4.3 Non-Voice Audible System Pathways 4.3.1 Pathways Class Designations and Survivability Pathways class: Survivability level: Quantity: (See NFPA 72,Sections 12.3 and 12.4) 4.3.2 Pathways Utilizing Two or More Media Quantity: Description: 4.3.3 Appliance Power Pathways ®No separate power pathways from the notification appliance pathway 0 Power pathways are separate but of the same pathway classification as the notification appliance pathway ❑Power pathways are separate and different classification from the notification appliance pathway NFPA 72, Fig. 10.18.2.1.1 (p 30112) Copyright©2009 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. 5. ALARM INITIATING DEVICES 5.1 Manual Initiating Devices 5.1.1 Manual Fire Alarm Boxes ❑This system does not have manual fire alarm boxes. Type and number of devices: Addressable: Conventional: Coded: Transmitter: Other(specify): Existing 5.1.2 Other Alarm Boxes LI This system does not have other alarm boxes. Description: Type and number of devices: Addressable: Conventional: Coded: Transmitter: Other(specify): 5.2 Automatic Initiating Devices 5.2.1 Smoke Detectors ❑This system does not have smoke detectors. Type and number of devices: Addressable: Conventional: Other(specify): Existing Type of coverage: ❑Complete area ❑Partial area ❑Nonrequired partial area Other(specify): Type of smoke detector sensing technology: ❑Ionization ❑Photoelectric 0 Multicriteria ❑Aspirating ❑Beam Other(specify): 5.2.2 Duct Smoke Detectors ❑This system does not have alarm-causing duct smoke detectors. Type and number of devices: Addressable: Conventional: Other(specify): Existing Type of coverage: Type of smoke detector sensing technology: ❑Ionization ❑Photoelectric ❑Aspirating ❑Beam 5.2.3 Radiant Energy(Flame)Detectors ®This system does not have radiant energy detectors. Type and number of devices: Addressable: Conventional: Other(specify): Type of coverage: 5.2.4 Gas Detectors ®This system does not have gas detectors. Type of detector(s): Number of devices: Addressable: Conventional: Type of coverage: 5.2.5 Heat Detectors ❑This system does not have heat detectors. Type and number of devices: Addressable: Exist Conventional: Exist Type of coverage: ❑Complete area 0 Partial area ❑Nonrequired partial area ❑Linear ❑Spot Type of heat detector sensing technology: ❑Fixed temperature ❑Rate-of-rise ❑Rate compensated NFPA 72, Fig. 10.182 1.1 (p. 4 of 12) Copyright©2009 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. 5. ALARM INITIATING DEVICES (continued) 5.2.6 Addressable Monitoring Modules ❑This system does not have monitoring modules. Number of devices: Existing 5.2.7 Waterflow Alarm Devices ❑This system does not have waterflow alarm devices. Type and number of devices: Addressable: Exist Conventional: Coded: Transmitter: 5.2.8 Alarm Verification ❑This system does not incorporate alarm verification. Number of devices subject to alarm verification: Existing Alarm verification set for seconds 5.2.9 Presignal ❑This system does not incorporate pre-signal. Number of devices subject to presignal: Describe presignal functions: 5.2.10 Positive Alarm Sequence(PAS) ®This system does not incorporate PAS. Describe PAS: 5.2.11 Other Initiating Devices ®This system does not have other initiating devices. Describe: 6. SUPERVISORY SIGNAL-INITIATING DEVICES 6.1 Sprinkler System Supervisory Devices ❑This system does not have sprinkler supervisory devices. Type and number of devices: Addressable: Conventional: Coded: Transmitter: Other(specify): Existing 6.2 Fire Pump Description and Supervisory Devices 0 This system does not have a fire pump. Type fire pump: ❑Electric pump 0 Engine Type and number of devices: Addressable: Conventional: Coded: Transmitter: Other(specify): Existing 6.2.1 Fire Pump Functions Supervised ❑Power ❑Running ❑Phase reversal ❑Selector switch not in auto 0 Engine or control panel trouble 0 Low fuel Other(specify): Existing 6.3 Duct Smoke Detectors(DSDs) ❑This system does not have DSDs causing supervisory signals. Type and number of devices: Addressable: Conventional: Other(specify): Existing Type of coverage: Type of smoke detector sensing technology: ❑ Ionization ❑Photoelectric ❑Aspirating El Beam 6.4 Other Supervisory Devices ❑This system does not have other supervisory devices. Describe: NFPA 72, Fig. 10.18.21.1 (p. 5 of 12) Copyright 0 2009 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. 7. MONITORED SYSTEMS 7.1 Engine-Driven Generator 0 This system does not have a generator. 7.1.1 Generator Functions Supervised 0 Engine or control panel trouble ❑Generator running ❑ Selector switch not in auto ❑ Low fuel ❑Other(specify): 7.2 Special Hazard Suppression Systems ❑This system does not monitor special hazard systems. Description of special hazard system(s): 7.3 Other Monitoring Systems ®This system does not monitor other systems. Description of special hazard system(s): 8. ANNUNCIATORS ❑This system does not have annunciators. 8.1 Location and Description of Annunciators Location 1: Existing Location 2: Location 3: 9. ALARM NOTIFICATION APPLIANCES 9.1 In-Building Fire Emergency Voice Alarm Communication System 0 This system does not have an EVACS. Number of single voice alarm channels: Number of multiple voice alarm channels: Number of speakers: Number of speaker circuits: Location of amplification and sound-processing equipment: Location of paging microphone stations: Location 1: Location 2: Location 3: 9.2 Nonvoice Notification Appliances ❑This system does not have nonvoice notification appliances. Horns: With visible: Bells: With visible: Chimes: With visible: Visible only: Other(describe): Existing 9.3 Notification Appliance Power Extender Panels ®This system does not have power extender panels. Quantity: Locations: NFPA 72, Fig. 10.18.2.1.1 (p. 6 of 12) Copyright©2009 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. 10. MASS NOTIFICATION CONTROLS, APPLIANCES, AND CIRCUITS ®This system does not have an MNS. 10.1 MNS Local Operating Consoles Location 1: Location 2: Location 3: 10.2 High-Power Speaker Arrays Number of HPSA speaker initiation zones: Location 1: Location 2: Location 3: 10.3 Mass Notification Devices Combination fire alarm/MNS visible appliances: MNS-only visible appliances: Textual signs: Other(describe): Supervision class: 10.3.1 Special Hazard Notification El This system does not have special suppression predischarge notification. ❑MNS systems DO NOT override notification appliances required to provide special suppression predischarge notification. 11. TWO-WAY EMERGENCY COMMUNICATION SYSTEMS 11.1 Telephone System El This system does not have a two-way telephone system. Number of telephone jacks installed: Number of warden stations installed: Number of telephone handsets stored on site: Type of telephone system installed: El Electrically powered ❑Sound powered 11.2 Two-Way Radio Communications Enhancement System ❑This system does not have a two-way radio communications enhancement system. Percentage of area covered by two-way radio service: Critical areas: % General building areas: Amplification component locations: Inbound signal strength: dBm Outbound signal strength: dBm Donor antenna isolation is: dB above the signal booster gain Radio frequencies covered: Radio system monitor panel location: NFPA 72, Fig. 10.1 8.2.1.1 (p.7 of 12) Copyright©2009 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. 11. TWO-WAY EMERGENCY COMMUNICATION SYSTEMS (continued) 11.3 Area of Refuge(Area of Rescue Assistance)Emergency Communications Systems ❑This system does not have an area of refuge(area of rescue assistance)emergency communications system. Number of stations: Location of central control point: Days and hours when central control point is attended: Location of alternate control point: Days and hours when alternate control point is attended: 11.4 Elevator Emergency Communications Systems 0 This system does not have an elevator emergency communications system. Number of elevators with stations: Location of central control point: Days and hours when central control point is attended: Location of alternate control point: Days and hours when alternate control point is attended: 11.5 Other Two-Way Communication Systems Describe: 12. CONTROL FUNCTIONS This system activates the following control fuctions: El Hold-open door releasing devices El Smoke management ❑HVAC shutdown ❑F/S dampers ❑Door unlocking ❑Elevator recall El Fuel source shutdown El Extinguishing agent release El Elevator shunt trip El Mass notification system override of fire alarm notification appliances Other(specify): Existing 12.1 Addressable Control Modules El This system does not have control modules. Number of devices: Other(specify): Existing 13. SYSTEM POWER 13.1 Control Unit 13.1.1 Primary Power Input voltage of control panel: 120 Control panel amps: 20 Overcurrent protection: Type: breaker Amps: 20 Location(of primary supply panel board): Disconnecting means location: 13.1.2 Engine-Driven Generator 0 This system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: NFPA 72, Fig 10.18.2.1.1 (p. 8 of 12) Copyright©2009 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. 13. SYSTEM POWER(continued) 13.1.3 Uninterruptible Power System Z This system does not have a UPS. Equipment powered by a UPS system: Location of UPS system: Calculated capacity of UPS batteries to drive the system components connected to it: In standby mode(hours): In alarm mode(minutes): 13.1.4 Batteries Location: FACP Type: acid Nominal voltage: 12 Amp/hour rating: 12 Calculated capacity of batteries to drive the system: In standby mode(hours): 24 In alarm mode(minutes): 10 ❑Batteries are marked with date of manufacture ❑Battery calculations are attached 13.2 In-Building Fire Emergency Voice Alarm Communication System or Mass Notification System ®This system does not have an EVACS or MNS system. 13.2.1 Primary Power Input voltage of EVACS or MNS panel: EVACS or MNS panel amps: Overcurrent protection: Type: Amps: Location(of primary supply panel board): Disconnecting means location: 13.2.2 Engine-Driven Generator ❑This system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: 13.2.3 Uninterruptible Power System 0 This system does not have a UPS. Equipment powered by a UPS system: Location of UPS system: Calculated capacity of UPS batteries to drive the system components connected to it: In standby mode(hours): In alarm mode(minutes): 13.2.4 Batteries Location: in radio Type: acid Nominal voltage: 12vdc Amp/hour rating: 12 Calculated capacity of batteries to drive the system: In standby mode(hours): In alarm mode(minutes): • 0 Batteries are marked with date of manufacture ❑Battery calculations are attached NFPA 72, Fig. 10.18.2.1.1 (p. 9 of 12) Copyright©2009 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. 13. SYSTEM POWER(continued) 13.3 Notification Appliance Power Extender Panels ❑This system does not have power extender panels. 133.1 Primary Power Input voltage of power extender panel(s): Existing Power extender panel amps: Existing Overcurrent protection: Type: Amps: Location(of primary supply panel board): Disconnecting means location: 13.3.2 Engine-Driven Generator ®This system does not have a generator. Location of generator: Location of fuel storage: Type of fuel: 13.3.3 Uninterruptible Power System ®This system does not have a UPS. Equipment powered by a UPS system: Location of UPS system: Calculated capacity of UPS batteries to drive the system components connected to it: In standby mode(hours): In alarm mode(minutes): 13.3.4 Batteries Location: Type: Nominal voltage: Amp/hour rating: Calculated capacity of batteries to drive the system: In standby mode(hours): In alarm mode(minutes): 0 Batteries are marked with date of manufacture 0 Battery calculations are attached 14. RECORD OF SYSTEM INSTALLATION Fill out after all installation is complete and wiring has been checked for opens,shorts,ground faults, and improper branching, but before conducting operational acceptance tests. This is a: ❑New system ®Modification to an existing system Permit number: The system has been installed in accordance with the following requirements:(Note any or all that apply.) ®NFPA 72, Edition: ®NFPA 70,National Electrical Code,Article 760,Edition: Z Manufacturer's published instructions Other(specify): System deviations from referenced NFPA standards: Signed: Printed name: Date: Organization: Performance Systems Title: Tech Phone: 503-641-2222 NFPA 72. Fig. 10.18.2.18.2.1.1.1 (p. 10 of 12) Copyright©2009 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. 15. RECORD OF SYSTEM OPERATIONAL ACCEPTANCE TEST ❑New system All operational features and funcfions of this system were tested by, or in the presence of the signer shown below, on the date shown below, and were found to be operating properly in accordance with the requirements for the following:• Z Modifications to an existing system All newly modified operational features and functions of the system were tested by, or in the presence of the signer shown below, on the date shown below,and were found to be operating properly in accordance with the requirements of the following: ❑NFPA 72, Edition: ❑NFPA 70,National Electrical Code, Article 760,Edition: 2017 ❑ Manufacturer's published instructions Other(specify): El Individual device testing documentation[Inspection and Testing Form(Figure 14.6.2.4)is attached] Signed: Printed name: Date: Organization: Performance Systems Title: Phone: 16. CERTIFICATIONS AND APPROVALS 16.1 System Installation Contractor: This system,as specified herein,has been installed and tested according to all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: 16.2 System Service Contractor: The undersigned has a service contract for this system in effect as of the date shown below. Signed: Printed name: Date: Organization: Title: Phone: 16.3 Supervising Station: This system,as specified herein,will be monitored according to all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: NFPA 72, Fig. 10.18 2.1.1 (p. 11 of 12) Copyright©2009 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. 16. CERTIFICATIONS AND APPROVALS (continued) 16.4 Property or Owner Representative: I accept this system as having been installed and tested to its specifications and all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: 16.5 Authority Having Jurisdiction: I have witnessed a satisfactory acceptance test of this system and find it to be installed and operating properly in accordance with its approved plans and specifications,with its approved sequence of operations,and with all NFPA standards cited herein. Signed: Printed name: Date: Organization: Title: Phone: NFPA 72, Fig. 10 18.2.1.1 (p 12 of 12) Copyright©2009 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.