Report (58) SYSTEM K� r:t "'COMPLETION
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1 hisfor m is to be completed by the Si feni installation contractor az the time of system acceptance.and approval.
it shall be permitted to wattl_;'this-form as needed to provide a more complete and/or clear record.
insert??WA in all unused lines.
Attach additional sheeet_r.data,or calculations as necessary ry to provide o complete record.
Form Completion Date: El— V— 17 Supplemental Pages Attached: .
.. PROPERTY PERTY INFORMA ION
: • // I
Name a=property
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,ddra: D , Sw GR. , - ., S I
n s
Description{3i}}"i�I7±.iF;t; ,. ,.
Name of property representative:
Address:
Phone: Fax: E-mail:
2. INSTALLATION,SI1" ICS.TESTING,AND MONITORING INF` R}JIA IOM
Installation contractor: f>r,4,f j "v.",� // i, _-
A,--,r
'X /Q/n /..) ,('S ✓o D.,lriI� a'
Address: �6 �d �1�
Phlone:93 4Z. --01 0 0 Fax: E-mail:
Service organization:
Address:
Phone: Fax: E-mail:
Testing organization:
Address:
Phone: Fax: E-mail:
Effective date for test and inspection contract:
Monitoring organization:
Address:
' F-1mail:
Phone: t'a•".
Account number: Phone line 1: Phone line 2:
Means of transmission:
Entity to which darns are retransmitted: Phone:
3. DOCUMENTATION /'�
On-site location of the required record documents and site-sosoftware:Cifi software: '9rj{�j-c/c) >
4. DESCRIP t ION Oi`s S[EM �R SERVICEThi_is a: 0 New system //n ^ q
.�=vlodif.cation to esistin6Y--S 2.O
t _s,ste n Permit number: � 000240
NFPA 72 edition: !
4.1 Control Unit �� �VY�
Model number: (
4.2 Software and Firmware
Firmware revision number.
=1.3 Alarm 4`ci'ii1C4tt}II
This system does not incorporate alarm verification.
?lumber of devices subject to alarm verification: Alarm verification set for seconds
Cwyricnn c.Eet2 Ust ertel Fire Thr tl i.^n As adsitca.Irrs lens may as copied tar it iI tdC_t use other tticn far resEls.Ii rile.nst Cs Espied tar as.i?rilart i saliar allia7J1iOn.
XS??jtf PwCORD OF'CifliMPL1!ON(conilinu )
3. ='Wir ITRA 711li1!F;
5.1 Control Unit
5.1.1 PT ITnal'y Power
Input voltage of control panel: /0,2U��1/�,9(.. Control panel amps:
tOvercunent protection: T'.pe: ��G-tt�Ti1G., . Amos: cvUl
Branch circuit disconnecting means location: L 2— Number: .1i''7)
5.1.2 Secondary Power
Type of secondary power: Bt9 kI Ci4s- 2 / 5 •+ (1
Location.if remote from the plant:
Calculated capacity of secondary power to drive the system:
in 3Lu'lliiV;=mode(IIOL=a): in alacrm mode(minutes):5. Unit
nit //// tt�!
E.l This system does not have power extender panels
E i Power extender panels are listed on supplementary skeet A
j. >ii ii T}AND R HW `i
3EitLj a 'y I
Pe. I Dual illiedia Pathway I Separate Pathway Class 1 Survivability ilI fr Levi:l
3inalins Line I 1
Device Power I j
I
initiation Device +
.`,otirlcatlonAppliance- I 1 }
7. Rime`!ANNUNCIATORS
Type 1 Location `
I
S. ii=ii t i1 T iN- 13-EVU..r n .
I Addressable or
l', a Quantity 1 Conventional Alarm or Supervisory Sanai:ta echriolony
Manual Pull St..'ons I I I f
1 I 1 1
Smoke Detectors
Duct Smoke Detect 1 1 1
Heat Detectors ! j 1 1
,
Das ►Detectors {
'\'atertioii'Switches I I i
Tamper Switches I 1 1
cn ete1,P23:2 Nawing=ire Prct=r?r--n?sc�aBcn.This f=rn may!Is ctp
P. NGTIFiciATION APPI IANC%,S
l"pa I Quantity 1 Description
Audible
I
ViEible I ✓ iSiMD/ex Al-dA) APG2c3r ._.
(T
combination Audible and Visible IR DO. ld
t
i0, zYsTailit Q iTROLFUN TIONS
Type i Quantity
Hold-Open Door!tele.. ing Devices
TIVAC Shutdown I
Fire/Smoke Dampers I
Door Unlock:ins I
I
Elevator Recall 1
Elevator Shunt"Dip
I
1.1: N1ERC.':ONMi 1S'mt..: SVE:1.MO
4 f This system does not have interconnected systems.
0 intercoIutected systems are lined on supplementary sheet
'12. CWRal IFIc 1IoN AN tt APPROVAL ;
12.1 System Installation Contractor
TIis syst- aysoecifte� •ein I s been installed according to ail`I P__standards cited herein.
Sinned: . ,I Printed name: g/LL (qi+.//.&.J Date:
Or_anization: t70M/% / .lc )c MSC isle: �fj�(Ai *yelA "' ?hone:34e-'-/3/—DV 1/
2
1 2 System Operational Test V
This syst t:a-s ed heI. n i^ns tested accordins to all NFPA standards cited herein.
Signe i o
i Primed name:1'IL , Al/ r•/ Date:
inaniz_tion/9OMJr ON/7;e2 69itle: ffJenb-,&)e i+4-e PLone: $6a-y3/ "O9/I
12.3 Acceptance Test V
Date and time of acceptance test:
I nstailine cona'acior representative:
Testing contractor representative:
Property j representative:
Alii representative:
Ccpyiih,tip.E072 Nations!rue Fret eces Assas6`m This Ic n may to c,:p:».1 i;,r irdr.':t_t c;<_citar i n for+rite.it r;ay am be c eie3 for caaarr=jdEi eale ez aiiiiktii"1.