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HomeMy WebLinkAboutB17-2940_040-200-006_CALFIRE INSPECTION 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: 3 129 I' Supplemental Pages Attached: 2- 1. PROPERTY INFORMATION 1 l Name of property: �tt�S�C�CA-c �od-A.LliC3oc S Address: _iZ IL JI"l,t 61„c6,,i 1).uVLAytt CIA q')C q3? Description of property: Ce y1i yiglr yr c ‘&\ C? .'AA-1,3C.('TVA, Name of property representative: TV c4-{-L Address: 2 Phone: 530Pglt 3.. �� Fax: 570- 51p 3-344 E-mail: 2. INSTALLATION, SERVICE,1TESTING,AND MONITORING INFORMATION Installation contractor: -S .A eC_rc trC� Address: (0 3 Z E,y'A- itt- V Phone: Q-G3 tp-L{Z 1 Fax: 5 o�yll� E-mail: Service organization: c...C.„5 E,\e cA-11- Address: -trAddress: S .ti ytti e Phone: Fax: E-mail: Testing organization: (L5 £ Address: l 6... Q Phone: Fax: E-mail: Effective date for test and inspection contract: I Z.°11 l� Monitoring organization:' ,� C v L (� 7 Address: L53 1 C_AtAY� Q{C.e \ cfe 1>c, L.C�t�t?'_ �Uf P��f �. 7 4 3O Phone: 94(1)- (oL-t )L Fax: E-mail: Account number: (...(.4-& ( O 7 R + Phone line 1: 1 Phone line 2: �,y/14 Means of transmission: oVe Qt.t-L GE'_V'. '.Aar Entity to which alarms are retransmitted: Phone: 3. DOCUMENTATION /� On-site location of the required record documents and site-specific software: FALL' "t•C>G. C.tn G . (;e'c 4. DESCRIPTION OF SYSTEM OR SERVICE This is a: 0 New system Modification to existing system Permit number: NFPA 72 edition: -Z.C)1`7 4.1 Control Unit Manufacturer: (`r `��� Model number: (KS - (/D 4.2 Software and Firmware Firmware revision number: KS 5 (0 v 3. 4.3 Alarm Verification This system does not incorporate alarm verification. Number of devices subject to alarm verification: Alarm verification set for seconds Copyright er 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. (p. 1 of 3) B17-2940 040-200-006 SYSTEM RECORD OF COMPLETION (continued) 5. SYSTEM POWER 5.1 Control Unit 5.1.1 Primary Power Input voltage of control panel: ( J AL Control panel amps: Overcurrent protection: Type: � z r ��r Amps: 20 Branch circuit disconnecting means location: LV 3 Number: ` Z 5.1.2 Secondary Power Type of secondary power: 5 Location,if remote from the plant: Calculated capacity of secondary power to drive the system: In standby mode(hours): . In alarm mode(minutes): 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 Other(specify): 7. REMOTE ANNUNCIATORS Type Location 8. INITIATING DEVICES Addressable or Type Quantity Conventional Alarm or Supervisory Sensing Technology Manual Pull Stations i C G r U Smoke Detectors Duct Smoke Detectors Heat Detectors ( Cots Pe �'���M.ko Gas Detectors Waterflow Switches t C c Q A try a'G _ ytkt+Lk- Tamper Switches L .* C.-Cd(\J i &i'net, I w e4 CtoW i1ew 4 To,.vkV,ef IVteu) „„\-1 ccrk t) 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. (p.2 of 3) SYSTEM RECORD OF COMPLETION (continued) 9. NOTIFICATION APPLIANCES Type Quantity Description D Audible '.7- (Zon.t 4' -\`S (Oi t\eU.) Z ._\l 1 et;b1A-tIG k.) Visible 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. ❑ Interconnected systems are listed on supplementary sheet _ . 12. CERTIFICATION AND APPROVALS 12.1 System Installation Contractor This system as specified herein as b n installed accordingto all NFPA standards cited herein. p Signed: �� ( Printed name: �c i TIA (1,‘04Date: (Z 1 (( ' Organization: S e (e( ' t( , Title: t Q Phone: 3 5`1 l S(3 12.2 System Operational Test This system as spe if ed h rein has teste according to all NFPA standards cited herein. f Signed: zLiz— Printed name: Ke.4-1, K4144 tsj Date: 31 Z4C11 rJ Organization: c_ES E f e Cj-j I( _ Title: )tc-14 Phone: 3s`'t-I 5/3 12.3 Acceptance Test //11 Date and time of acceptance test: -3 /Z-4'1 S,4A/ =00 4 l( Installing contractor representative: , Testing contractor representative: - '411111. ,.... / Property representative: X / 0 AHJ representative: }[ )0.i - 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. (p. 3 of 3)