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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 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: 11/30/16 Supplemental pages attached:
1. PROPERTY INFORMATION
Name of property: Lundberg Building 8
Address: 5311 Midway Building #8
Description of property: Commercial
Name of property representative:
Address:
Phone: Fax: E-mail:
2. INSTALLATION, SERVICE, TESTING, AND MONITORING INFORMATION
Installing contractor: Foothill Fire Alarm & Security, Inc.
Address: 170 Erma Ct, Chico, CA 95928
Phone: (530) 826-3013 Fax: (530) 893-3013 E-mail: alarms@ffprotection.com
Service organization: Foothill Fire Alarm & Security, Inc.
Address: 170 Erma Ct, Chico, CA 95928
Phone: (530) 826-3013 Fax: (530) 893-3013 E-mail: alarms@ffprotection.com
Testing organization: Foothill Fire Alarm & Security, Inc.
Address: 170 Erma Ct, Chico, CA 95928
Phone: (530) 826-3013 Fax: (530) 893-3013 E-mail: alarms@ffprotection.com
Effective date for test and inspection contract: 11/21/16
Monitoring organization: Foothill Fire Alarm & Security, Inc.
Address: 170 Erma Ct, Chico, CA 95928
Phone: (530) 826-3013 Fax: (530) 893-3013 E-mail: alarms@ffprotection.com
Account number: Z570101 Phone Zine 1/IP: 1 (844) 414-0165 Phone line 2/IP: 1 (844) 414-0165
Means of transmission: Cellular
Entity to which alarms are retransmitted: Rapid Response Phone: (800) 932-3822
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3. DOCUMENTATION
Onsite location of the required record documents and site-specific software: Document Box
4. DESCRIPTION OF SYSTEM OR SERVICE
This is a: ® New system ❑ Modification to existing system Permit number:
4.1 Control Unit
Manufacturer: Potter Model number: PFC-6800
4.2 Software and Firmware
Firmware revision number:
4.3 Alarm Verification ® This system does not incorporate alarm verification
Number of devices subject to alarm verification:
Alarm verification set for seconds
5. SYSTEM POWER
5.1 Control Unit
5.1.1 Power Primary Power
Input voltage of control panel: 120 Control panel amps: 20
Overcurrent protection: Type: Circuit Breaker Amps: 20
Branch circuit disconnecting means location: Number:
5.1.2 Secondary Power
Type of secondary power: Battery (2) 12V
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
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6. CIRCUITS AND PATHWAYS
Pathway Type
Dual Media
Pathway
Separate
Pathway
Class
Survivability
Level
Signaling Line
1
X
B
2
Device Power
Waterproof Horn Strobe
N/A
N/A
N/A
Initiating Device
N/A
N/A
N/A
Notification Appliance
1
x
B
2
Other (specify):
N/A
N/A
N/A
7. REMOTE ANNUNCIATORS
Type
Location
8. INITIATING DEVICES
Type
Quantity
Addressable or
Conventional
Alarm or Supervisory
Sensing Technology
Manual Pull Stations
1
Addressable
Alarm
N/A
Smoke Detectors
Waterproof Horn Strobe
N/A
N/A
N/A
Duct Detectors
N/A
N/A
N/A
Heat Detectors
1
Addressable
Alarm
Rate -of Rise
Gas Detectors
N/A
N/A
N/A
Waterflow Switches
4
Addressable w/Modual
Alarm
N/A
Tamper Switches
5
Addressable w/Modual
Supervisory
N/A
9. NOTIFICATION APPLIANCES
Type
Quantity
Description
Audible
Visible
Combination Audible & Visible
2
Waterproof Horn Strobe
Page 3 of4
10. SYSTEM CONTROL FUNCTION
Type
Quantity
Hold -Open Door Releasing Device
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 supplemental sheet
12. CERTIFICATION AND APPROVALS.
12.1 System Installation Contractor
This system as specified herein has been installed according to all NFPA standards cited herein.
Signed: "Printed Name: Shane DeValera Date: 11/30/2016
Organization: Foothill Fire Alarm & Security, Inc. Title: Field Supervisor Phone: (530) 826-3013
12.2 System Operational Test
This system as specified herein has been tested according to all NFPA standards cited herein.
Signed: Printed Name: Shane DeValera Date: 11/30/2016
Organization: Foothill Fire Alarm & Security, Inc. Title: Field Supervisors Phone: (530) 826-3013
12.3 Acceptance Test
Date and time of acceptance test: Date: J /G,- Time: %/x/4.4
Installing contractor representative:
Testing contractor representative:
Property representative:
AHJ representative:
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