Report (116) •
SYSTEM RECORD OF COMPLETION ci) 5 Lo
This form is to be completed by the system installation contractor at the time of system accep ince a n cpprovaa [.
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: 06-14-18 Supplemental Pages Attached:
1. PROPERTY INFORMATION
Name of property: Lincoln Tower 10th Floor Suite 1055
Address: 10260 SW Greenburg Rd.Tigard,OR. 97223
Description of property: B-AHC Business Group(Ambulatory Health Care)
Name of property representative: Shorenstien Realty Services
Address: 10220 SW Greenburg Rd.Tigard,OR.97223
Phone: Fax: E-mail:
2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION
Installation contractor: Capitol Electric
Address: 11401 Marx St. Portland,OR.97220
Phone: Fax: E-mail:
Service organization: JCI
Address: 6305 SW Rosewood St Lake Oswego,OR.97035
Phone: 503-683-9000 Fax: E-mail:
Testing organization: Cosco Fire
Address:
Phone: Fax: E-mail:
Effective date for test and inspection contract:
Monitoring organization: Advantage Protection
Address:
Phone: Fax: E-mail:
Account number: 5224 Phone line I: Phone line 2:
Means of transmission: SDACT
Entity to which alarms are retransmitted: Phone:
3. DOCUMENTATION
On-site location of the required record documents and site-specific Fire Alarm Panel
software:
4. DESCRIPTION OF SYSTEM OR SERVICE
This is a: 0 New system Modification to existing system Permit number:
NFPA 72 edition: 2013
4.1 Control Unit
Manufacturer: Simplex Model number: 41000
4.2 Software and Firmware
Firmware revision number: 12.05.05
43 Alarm Verification .: This system does not incorporate alarm verification.
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)
5. SYSTEM POWER
5.1 Control Unit
5.1.1 Primary Power
Input voltage of control panel: 120vac Control panel amps: 8
Overcurrentprotection: Type: Breaker Amps: 20
Branch circuit disconnecting means location: 3EL Number: 1
5.1.2 Secondary Power
Type of secondary power: Fire Alarm Power Supply
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
Device Power
Initiating Device
Notification Appliance 1 B
Other(specify):
7. REMOTE ANNUNCIATORS
Type Location
8. INITIATING DEVICES
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 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.
SYSTEM RECORD OF COMPLETION (continued)
9. NOTIFICATION APPLIANCES
Type Quantity Description
Audible
Visible 5 Wall Mount Device
Combination Audible and Visible
10. SYSTEM CONTROL FUNCTIONS
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.
0 Interconnected systems are listed on supplementary
sheet
12. CERTIFICATION AND APPROVALS
12.1 System Installation Contractor
This system as specified h ein has bee • tailed according to all NFPA standards cited herein.
Signed: Printed ' 1 Date: 06-14-18
name: I�E'Ih 1/3 1sUyL
Organiza• n: Capitol Electr Title: Foreman Phone: sc.. 3i B 9S$9
12.2 System Operational Test
This system as sp• .'ed herein has : ted according to all NFPA standards cited herein.
Signed: .//'d'/� ': ted Ralph MacRoberts Date: 06-14-18
name:
Organi ion: JCI / Title: Tech Rep Phone: 503-683-9000
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.
•
SYSTEM RECORD OF COMPLETION (continued)
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.