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SYSTEM RECORD OF COMPLETION
This form is to be completed by the system Installation contractor at the time of system acceptance and approval.
It shall be permitted to modity 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: 5/9/19 Supplemental Pages Attached: 1
1. PROPERTY INFORMATION
Name of property: Triangle Corporate Park III-Centene
Address: 13221 SW 68th Pkwy Suite 300 Tigard,OR 97223
Description of property: Suite 300-Tenant Improvement
Name of property representative: CBRE
Address: 13221 SW 68th Pkwy Tigard,OR 97223
Phone: 503-701-8953 Fax: E-mail:
2. INSTALLATION,SERVICE,TESTING,AND MONITORING INFORMATION
Installation contractor: PROTEK SYSTEMS,LLC
Address: 305 SE Chkalov Drive Suite 111#361 Vancouver,WA 98683
Phone: (360)314-2017 Fax: E-mail: admin@protek.systems
Service organization: PROTEK SYSTEMS,LLC
Address: 305 SE Chkalov Drive Suite 111#361
Phone: (360)314-2017 Fax: E-mail: admin@protek.systems
Testing organization: PROTEK SYSTEMS,LLC
Address: 305 SE Chkalov Drive Suite 111#361
Phone: (360)314-2017 Fax: E-mail: admin@protek.systems
Effective date for test and inspection contract: 12/5/18
Monitoring organization: Central Station Monitoring
Address:
Phone: Fax: E-mail:
Account number: Phone line 1: Phone line 2:
Means of transmission:
Entity to which alarms are retransmitted: N/A Phone: N/A
3. DOCUMENTATION
On-site location of the required record documents and site-specific software: 1st Floor-FACP
4. DESCRIPTION OF SYSTEM OR SERVICE
This is a: LI New system Sl Modification to existing system Permit number: FPS2019-00048
NFPA 72 edition: 2013
4.1 Control Unit
Manufacturer: EST Model number: 2
4.2 Software and Firmware
Firmware revision number: N/A
4.3 Alarm Verification 11 This system does not incorporate alarm verification.
Number of devices subject to alarm verification: Alarm verification set for seconds
02012 National Fire Protection Association NFPA 72(p.1 of 3)
2013 Edition #
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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: 3.6A
Overcurrent protection: Type: Breaker Amps; 20A
Branch circuit disconnecting means location: House Panel Number:
5.1.2 Secondary Power
Type of secondary power: Batteries-12VDC 7AH
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 dries not have power extender panels
5i Power extender panels are listed on supplementary sheet A
6. CIRCUITS AND PATHWAYS
Dual Media Separate Survivability
Pathway Type Pathway Pathway Class Level
Signaling Line X B 0
Device Power
Initiating Device
Notification Appliance X B 0
Other(specify):
7. REMOTE ANNUNCIATORS
Type Location
S-BUS Lobby
8. INITIATING DEVICES
Addressable or Alarm or Sensing
Type Quantity Conventional Supervisory Technology
Manual Pull Stations Existing
Smoke Detectors Existing
Duct Smoke Detectors Existing
Heat Detectors Existing
Gas Detectors N/A
Waterflow Switches Existing
Tamper Switches Existing
0 2012 Natbnal Fire Protection Association NFPA 72(p.2 o1 3)
SYSTEM RECORD OF COMPLETION (continued)
9. NOTIFICATION APPLIANCES
Type Quantity Description
Audible
Visible 2 Strobe
Combination Audible and Visible 1 Horn Strobes
10. SYSTEM CONTROL FUNCTIONS
Type Quantity
Hold-Open Door Releasing Devices Existing
HVAC Shutdown Existing
Fire/Smoke Dampers Existing
Door Unlocking Existing
Elevator Recall Existing
Elevator Shunt Trip Existing
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11. INTERCONNECTED SYSTEMS
This system does not have interconnected systems.
Interconnected systems are listed on supplementary sheet
12. CERTIFICATION AND APPROVALS
12.1 System Installation Contractor
This system as specified heroin has been installed according to all NFPA standards cited herein.
Signed: 4 c5Gu2 Printed name: Adam Sweet Date: 5/9/19
Organization: PROTEK SYSTEMS,LLC Title: Fire Alarm Systems NICET III Phone: (253)448-1604
12.2 System Operational Test
This system as specified herein has tested according to all NFPA standards cited herein.
Signed: .Aedam 310444- Printed name: Adam Sweet Date: 5/9/19
Organization: PROTEK SYSTEMS,LLC Title: Fire Alarm Systems NICET III phone: (253)448-1604
12.3 Acceptance Test
Date and time of acceptance test: 5/9/19 -6:00am
installing contractor representative: Adam Sweet
Testing contractor representative: Randy Geyman
Property representative:
AHJ representative:
0 2012 National Fire Protection Association NFPA 72(p.3 of 3)
NOTIFICATION APPLIANCE POWER PANEL
SUPPLEMENTARY RECORD OF COMPLETION
This form is a supplement to the System Record of Completion.It includes a list of types and locations
of notification appliance power extender panels.
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.
Form Completion Date: 5/9/19 Nirnber of Supplemental Pages Attached: 1
1. PROPERTY INFORMATION
Name of property: Centene
Address: 13221 SW 68th Pkwy
2. NOTIFICATION APPLIANCE POWER EXTENDER PANELS
Make and Model Location Area Served Power Source
Silent Knight 5495 3rd Floor Elec Rm 3rd Floor 120VAC
See Main System Record of Completion for additional Information,certifications,and approvals.
0 2012 National Fire Protection Association NFPA 72