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Report Fes z 0/1- 00 e3. l Page 1 of 1 Copyright by National Fire Protection Association(NFPA).NFPA 72 is licensed,by agreement for individual use.No other reproduction or transmission in any form permitted without written permission of NFPA.For inquiries or to report unauthorized use,contact licensina(n nfoa.ora. 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 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: �// Supplemental Pages Attached: i 1. PROPERTY INFORMATION jj • Name of property; Ft C, rtt 5 Address: / 5 c 0 5 vv 5 (,C kir� t I f)2ii� c Description of property: 14,111-Gtr'.Ol I O cve- Gt&. id'Iv Name of property representative: N J Address: Phone: N A Fax: k E-mail: aI/A 2. INSTALLATION,SERVIQE,TESTING,�AND MONITORING INFORMATION Installation contractor: Gt`h t I o'Ct} Address: S 563 i G kite j0,'eW b I v h L 'k 'O jvv o Cie Fax: 'ilS�r Email; N Service organization: Address: I I Phone: t I Fax: 11 E-mail: Testing organization: Address: Phone; l t Fax: it E-mail: `I Effective date for test and inspection contract: AI/4 Monitoring organization: AiJt• . Address: Ju/ . . .. Phone: Ay/ Fax: E-mail:®� �'k Account number: r AO Phone line 1: /1/ Phone line 2: 11/4 Means of transmission: f/A• ®� • Entity to which alarms are retransmitted: ftr/'dt' Phone: Attie 3. DOCUMENTATION On-site location of the required record documents and site-specific software: - 4. DESCRIPTION OF SYSTEM OR SERVICE n r This is a: Q New system Modification to existing system Permit number: 9)5 NFPA 72 edition: `l-n I t 4.1 Control Unit , Manufacturer i k R % t Model number: 1 i -- 4.2 Software and Firmware ✓A' Firmware revision number: !v 4.3 Alarm Verification 01,This system does not incorporate alarm verification. Number of devices subject to alarm verification: Alarm verification set for seconds 20i2 National Fire Protection Association NFPA 72(p.1 of 3) FIGURE 7.8.2(a) System Record of Completion.(SIG-FUN) http://codesonline.nfpa.org/imagejspop.php?id=2013_G72-201&page=l&printpage=1 11/26/2014 Page 1 of 1 Copyright by National Fire Protection Association(NFPA).NFPA 72 is licensed,by agreement for individual use.No other reproduction or transmission in any form permitted without written permission of NFPA.For inquiries or to report unauthorized use,contact licensingenfna,ore. SYSTEM RECORD OF COMPLETION (continued) 5. SYSTEM POWER 5.1 Control Unit . 5.1.1 Primary Power • Input voltage of control panel: ��✓ Control panel amps: 1Overeurrentprotection: Type: SrkAmps: Branch circuit disconnecting means location: Number 5.1.2 Secondary Power Type of secondary power; fay 7e � Location,if remote from the plant: Wit ff Calculated capacity of secondary power to drive the system: In standby mode(hours): >LI in alarm mode(minutes): S 5.2 Control Unit a.This system does not have power extender panels 0 Power extender panels are listed on supplementary sheet A 6. CIRCUITS AND PATHWAYS Dual Media Separate Survivabilit Pathway Type Pathway Pathway Class Leve Signaling Line Device Power Initiating Device Notification Appliance Other(specify): 7. REMOTE ANNUNCIATORS type, Location 8. INITIA UI DEVICES Addressable or Alarm or Sensing Type Q Conventional Supervisory .._ dogy_.m....__...__..._, Manual Pull Stations Smoke Detectors Duct Smoke Detectors Heat Detectors Gas Detectors Waterflow Switches Tamper Switches ©2912 National Fire Protection Association NFPA 72(p.2 of 3) FIGURE 7.8.2(a) Continued http://codesonline.nfpa.org/imagej spop.php?id=2013_G72-202&page=l&printpage=1 11/26/2014 Page 1 of 1 Copyright by National Fire Protection Association(NFPA).NFPA 72 is licensed,by agreement for individual use.No other reproduction or transmission in any form permitted without written permission of NFPA.For inquiries or to report unauthorized use,contact licensin a nfpa.ore. SYSTEM RECORD OF COMPLETION (continued) 9. NOTIFICATION APPLIANCES Type quantity Description Audible Visible II W14,t IPL, ` -e)(CCct e/'. Combination Audible and Visible 3 1 ) /) 10. SYSTEM CONTROL FUNCTIONS --„•,__— ' Qtye Hold-Open Door Releasing Devices • HVAC Shutdown ®y.•- Fire/SmokeevatoDampers �.- .,._ Door Unlocking Elevator Recall 7.—:.___.--..—..- • Elevator Shunt Trip 11. INTERCONNECTED SYSTEMS air This system does not have interconnected systems. LI Interconnected systems are listed on supplementary sheet . • 12. CERTIFICATION AND APPROVALS • 12.1 System Installation Contractor - - This system as specified ddd herein� has been installed according to all NFPA standards cited herein. Signed: ����� �� Printed name: t'>'TYte C' Nli li Date: 7 �/ Organize�'°� ,44,74/ter Rule:L 54 , (Krim 1 Phone: 5- )--10 1)1 12.2 System Operational Test This system as specified herein has tested according to all NFPA standards cited herein. Signed: Printed name: "'1 Date: i i - Organization: 1\ Title: I I Phone: 1 } 12,3 Acceptance Test Date and time of acceptance test: Installing contractor representative: $( (e i1 ;�f1 Testing contractor representative: / Property representative: AHJ representative: .. ,,-..._. 02012 National Fire Protection Association NFPA 72(p.3 of 3) FIGURE 7.8.2(a) Continued • http://codesonline.nfpa.org/imagej spop.php?id=2013_G72-203&page=l&printpage=l 11/26/2014