HomeMy WebLinkAboutFire Alarm & Emergency Communication RecordFIRE ALARM AND EMERGENCY COMMUNICATION SYSTEM RECORD OF COMPLETION
To he completed hy the .\l's/em i11.rtallatio11 colllractor tJI the time of system acceptance and approval.
It shall he permilled to modify this form as needed to provide a more complete and/or clear record.
In sert N rl in all 1m11sed lines.
AllCtclt additional sheets. dCtta , or cak11/C1tio11s as necessary to provide" complete record
1. PROPERTY INFORMATION
Name of property: Atlantic Aviation Services F.B 0 Renovation
Address: 375 County Road 352 Building #2070 Rifle . CO
Description nr property : Aircraft Hangar/Offices
Occupancy 1ypc: S-2
Name of propcrt} representative: Tecton c Management Group
Address: 6695 West 4B'h Ave. Wheat Ridge, CO 80033
Phone: 303-403-1228 f'ux: E-mail:
Aut hority hnvingjurisdiction over this property: Rifle Fire Protect on District
Phone : 970·625-1243 f'a x: E-mail:
2. INSTALLATION, SERVICE, AND TESTING CONTRACTOR INFORMATION
Installation contractor for this equipment: Commercial Specia ists , Inc.
Address: 601 Mulberry Street , Grand Junction CO 81501
License or cer1ificmion number: NICET CERTIFIED
Phone: (970) 241-0268 Fa x: E-mail:
S..:rvicc organi zation for this equipment: Commercial Specialists, Inc
Address: 601 Mu l berry Street. Grand Junction CO 81501
License or certification number: NICET CERTIFIED
Phone: rax: E-mail :
/\contract for test and inspection in accordance with NFPJ\ standards is in effect as or:
Contracted te sting company:
Address:
Phone: r:Lx ; E-mail :
Contract ell.pircs: Contract number: Frequency of routine inspections :
3. DESCRIPTION OF SYSTEM OR SERVICE
181 Fire alann system (nonvoice)
D rire alarm with in-building lire emergency voice alarm communication system (EV /\CS)
D Mass notification system (MNS)
0 Combination sy sh:m. with the following component s:
0 Fire ulann
D Other (specify):
0 EVAC S 0MNS 0 Two-way . in-building. emergency communication system
Copyrighl Cl 2009 National F Jfe Pro1ee11on Association This form may be copied for 1nd1vidual use other lhan for resale II may nol De copied lot commercial sale or d1s1r1bul1on
3. DESCRIPTION OF SYSTEM OR SERVtCE (continued)
NFl'A 72 edilion: 2010 Additionul description of~)'stcm(s): FIRE ALARM SYSTEM
3. t Control Unit
Manufoctuser: NOTIFIER
3 .2 Mass Notification System
3.2.l System Ty1>c:
Model number: NFW 2-100
181 '111is system do~'S nol incorporate an MN~
0 ln-huitding MN~ -combination
0 111-buildlng MNS -stamJ-alone
0 Other (specily):
0 Wide-area MNS 0 DistrihutcJ recipient MNS
3 .2.2 System Features:
0 Combination lire alarm/MNS 0 MNS autonomous control unit 0 Wide-area MNS to regional m1t io11al
ulcrting imerface
0 Local opcrnting console (LOC) 0 Direct recipient MNS (DRMNS) 0 Wide-area MNS to DRMNS int erface
0 Wide-area MNS lo high-power speaker array (llPSA) interface 0 In-buildin g MNS Lo wide-area MNS inter foc e
0 Other (specily):
3.3 System Document:ition
f8I An owner's manual, a copy of the manufacturer's instructions, a writlcn sequence of operntion, and a copy of
1hc numbered record drawings arc ~tored on site. Location: In FACP
3.4 System Sortwnre 0 Th~s system docs not have alterable site-spccillc soil ware.
Operating system (executive) sollware revision level: v7 .1
Site-specilic sollware revision dale : June, 20t6 Revision completed by : Commercial Specialis ls
181 A copy of the sitc-spccilic soHwarc is slorcd on site. toeution: IN FACP
3.5 Off-Premises Signal Transmission 0 Th is sysle m docs not have off-premises transmission.
Numc of organi zation receiv ing alarm signals with phone numbers :
Alarm : CRITICOM MONITORING
Supervisory: CRITICOM MONITORING
Trouhle: CRITICOM MONITORING
1:111i1y lo \\hich <1lar111s arc retransmitted: GARFIELD COUNTY DISPATCH
Method of retransmission : ANALOG PHONE LINES
Phone : 1 ·800·631 ·2299
Phone : 1·800·631-2299
Phone: 1-800-631-2299
Phone; 970·625-8095
If Chapter '.?6 . spccily the means of transmission from the proll.'"Ctcd prcmiS\.'S to the 3upcrvis ing station:
NIA
If Chapler '.?7. specily the type o f auxiliary alaml system : 0 Local ene rgy 0 Shunt 0 Wir~-J [J Win:lcs.'
Copyr.ghl 0 2009 f\1 """'1<11 Fie PrOloetoon As~ton This IO<m may be copied for ondtvidual use other l han tor resale k m;iy not be copied for et>mmeroal sOle or dis\Obuhon
3. DESCRIPTION OF SYSTEM OR SERVICE (continued)
NF/'11 72 edition: 2010 Additional description of system(s): FIRE ALARM SYSTEM
3.1 Control Unit
Manufacturer: NOTIFIER
3.2 Mass Notification System
3.2.1 System Type:
Model number: NFW 2-100
181 This system docs not incorporate an MNS
0 In-building MNS-combination
0 In-building MNS -stand-alone
0 Other (spccily):
0 Wide-area MNS 0 Distributed recipient MNS
3.2.2 System features:
0 Combination lire alarmlMNS 0 MNS autonomous control unit O Wi<lc-area MNS to regional national
alerting interface
0 Local operating console (LOC) O Direct recipient MNS (DRMNS) 0 Wide-area MNS to DRMNS interface
O Wide-area MNS to high-power speaker array (I IPSA) interface 0 In-building MNS to wide-area MNS interface
0 Other (specify):
3.3 System Documentation
(81 An owner's manual. a copy of the manufacturer's instructions, a wriucn sequence of operation. an<l a copy of
the numbered record drawings arc stored on site. Location: In FACP
3.4 System Software 0 This system docs not have alterable site-specific sollware.
Operating system (executive) soil ware revision level : v7.1
Site-spccilic sollware revision d:11e: June, 2016 Revision completed by: Commercial SpecialtSts
181 A copy of the site-specific software is stored on site. Location: IN FACP
3.5 Off-Premises Signal Transmission 0 This system docs not have on:premises trnnsmission.
Name of orguni1.ation receiving alarm signals with phone numbers:
Alarm: CRITICOM MONITORING
Supervisory: CRITICOM MONITORING
Trouble: CRITICOM MONITORING
Entity to which alarms arc retransmitted: GARFIELD COUNTY DISPATCH
Method of retransmission: ANALOG PHONE LINES
l'honc: 1-800-631·2299
Phone: 1-800-631-2299
Phone: 1-800-631-2299
Phone: 970-625-8095
II' Chapter 26. specify the means of transmission from the protected premises to the supervising station:
NIA
ll"Chapter 27. spccily the type of' auxiliary alarm system: 0 Local energy 0 Shunt 0 Wired 0 Wireless
Copynghl 0 2009 National F~a Proccclioo As50Cl:ihon This r0<m may be copied for lfldividoal use other lhan tor resale It may noc be copied for commercial sale or doslnbullon
4. CIRCUITS AND PATHWAYS
4.1 Signnling Linc r11thwnys
4.1.1 r11thw:1ys Class Designations and Survivability
Pallmuys class: B Survivabilily level : 0 Quan1i1y:
(See NFf',I 72, Sections 12.3 mid 12..1)
4.1.2 Pnthways Utilizing Two or More Media
Quantity: 0 Description:
4.1.3 Device Power Pathways
[8J No separate power pathways from the signaling line palhway
D Power pathways arc sepumte bul of the same palhway classification as the signaling line pathwuy
D Power palhways arc scpamle and difTerent clussilication from the signaling line pathway
4.1.4 lsolntion Modules
Quantity: 0
4.2 Alarm lnili11ting Device Pnthwnys
4.2.1 P:1thwnys Cl:lSS Designntions 11nd Survivability
Pathways class: B Survivabilily level : 0 Quantity:
(See NFl'1I 72. Sectirms 12.3 cmd 12 ./)
4.2.2 Pnthwnys Utilizing Two or More Medill
Quantity· O Descri ption:
4.2.3 Device Power Pathwnys
[8J No separntc power pathways from the initiating device palhway
D Power palhways arc separate but of the same pathway classification as the initiating device pathway
D Power pathways arc separate and d ifferent class ification from the initiating device pathway
4.3 Non-Voice Audible System Pathways
4.3.1 Pathways Cl:iss Designations nnd Survivnbility
Pathways class: 0 Survivnbillty level : 0 Quantity:
(See NF!':! 72. Section s 12.3 mu/ 12 . ./)
4.3.2 Pnthwnys Utilizing Two or More Media
Quantity: O Description:
4.3.3 Appliance Power Pathways
£81 No separate power pathways from the not i1 fication appliance pathway
3
0
D Power pathways arc scparah: hut of the same pathway classification as the notilicalion appliance pathway
D Power pathways arc separate and dini:rcnt class ification from the notification appliance pathway
Copyright 0 2009 National Fue Protection AssaccatlOO This form may be copied lat ind<vidua use olher Chan lat resale II may not be copi ed 10< oommerc:i.i sale or dcs1t11>ucoon
5. ALARM INITIATING DEVICES
5.1 M:mual lnitinting Devices
5.1 .1 Manual Fire Alarm Boxes
l'ypc and number o f devices: Addressable:
Other ( six-ci ly ):
5.1.2 Other Al:irm Boxes
Dcsc rirtion:
r ypc :md numhcr of devil.:cs: Addn."Ssitblc:
Other (spccily):
5.2 Automatic lnifo11ing Devices
5.2.1 Smoke Octeclors
8
I )pc and number of devices: Addrc!>S<lble: 4
Other (spccily):
0 ·mis !>)'Stem docs not have manual fin.: al arm bo~es.
Conventional : Coded: Tr.msm iucr:
181 l 'his system docs not have other alarm boxes.
Conventional : Cm.Ice.I : rrans miucr:
0 This sys1cm docs not have s moke dc1cctors.
Convent ional :
l'ypc of coverage: 0 Comrlctc area 181 Partia l a rea 0 Nonrequired partial area
Other (speci ly):
I') pc of smo ke detector sensing lecht111logy: 0 Ionization l8I Pl1otoelcctric 0 Muhic.:ritcria 0 Aspirating 0 Ucam
Other (specify):
5.2.2 Duct Smoke Detectors 181 This syslcm docs nol have al1urm-causing duct smoke tklcctors.
J'ypc and number nf devices: Addressable: Conventional :
Other (s pccily):
·1 ypc of coverage:
l'ype of smoke detector sensing technology: 0 Ion ization 0 Photoelectric 0 Aspir.iting 0 Beam
5.2.3 l~ndiant Energy (fl:\me) Detectors
rype and number of devi1..-cs : Addressable:
Othcr (spcci ly):
I ypc o f covcrnge:
5.2.4 Gns Detectors
l'ype or detcctor(s):
Number of devil.:cs: Addressable:
Type or coverage:
5.2.5 lle;1t Detectors
l"ypc and number of dev ic.:es: AJ drcs!-a ble;
181 This system docs not have radiant energy delcc.:torl>.
Convcntinnal:
181 Thi s system docs not have g;L~ dclcc lm s.
Conventional:
181 l'his system docs not have heal <k lcclors.
Convenlinnal:
T ype of coverage: 0 Complete area 0 Partial area 0 Nonrequired partial area 0 Linear 0 Spot
I) pc of heal detector sens ing techno logy: 0 ri~cd lcrnperaturc 0 ltalc·of·risc 0 Rate compcnsmcd
Copyt•Jhl 0 2009 Nollonal F<o Pro1oc1oot1 Assocsat1on This IOtm may be coptod lot 1ndov1cbal use olher lhan lor re$81o lt "'ay nol be copied fo r commero aJ sale ot d1slnbut on
5. ALARM INITIATING DEVICES
5.1 Manual Initiating Devices
5.1.I Mnnunl Fire Alnrm Boxes
l"ypc and number of devices: Addressable: 8
Other (sru:cify):
5.1.2 Other Alarm Boxes
Description :
I ypc ;md number of devices: Addressable:
Other (specify):
5.2 Automatic lnitinting Devices
5.2.1 Smoke Detectors
l"ype and number of devices: Addressable : 4
Other (spccily);
D This system docs not huvc manual lire alarm boxes.
Conventional : Coded: TrJnsmittcr:
181111is system docs not have other alarm boxes.
Conventional: Coded: Transmitter:
D This system docs not have smoke detectors.
Conventional :
Type of coverage: 0 Complete urea 181 Partial area D Nonrequired partial area
Other (specify):
Type of smoke detector sens ing technology : 0 Ionization 181 Photoelectric 0 Multicritcria 0 /\spiraling 0 Beam
Other (specify):
5.2.2 Duct Smoke Detectors 181 This system docs not have alarm-causing duel smoke detectors.
Type and number of devices: Addrc.•1.,c;ablc: Conventional:
Other (spccily):
Type of coverage:
Type of smoke detector sensing technology: 0 Ionization 0 Photoelectric 0 Aspimting 0 Ileum
5.2.J Radiant Energy (Flnme) Detectors
Type und number of devices: Addressable:
Other (specify):
Type of coverage:
5.2.4 Gas Detectors
Type of dctector(s):
Number of devices: Addressable:
Type of coverage:
S.2.5 J-le11t Detectors
181 This system docs not have radiant energy detectors.
Conventional:
181 TI1is system docs not have gas detectors.
Conventional:
181 This system docs not have heal detectors.
Type and number of devices: Addressable: Conventional:
Type of coverage: 0 Complete area 0 Partial area 0 Nonrequired partial area 0 Linear 0 Spot
Type of heat detector sensing technology: 0 Fixed temperature 0 Rate-of-rise 0 Rate compensated
Copyrijjhl 0 2009 National Fire Proloc~on Associatoon This ronn may b& copied for 1ncl1v1dual use other than for tosale. II may not be copied for commorc:.al sale or di slnbut1on
5. ALARM INITIATING DEVICES (continued)
5.2.6 Addressable Monitoring Modules
Number of devices: 6
5.2.7 Wnterflow Alarm Devices
l'ype aml number of devices: Addressable :
5.2.8 Alnrm Verification
Number of devices subject to ulann verification:
5.2.9 Presignnl
Number of devices su~iect lo presignal:
Describe presignal fUnctions:
5.2.IO Positive Alarm Sequence (PAS)
IA-scribe PAS:
5.2.11 Other Initiating Devices
lkscribe:
0 This system docs not have monitoring modules.
0 1 his system docs not have watcrnow alarm devices.
Conventional: Coded: Trnnsmillcr:
181 This system docs not incorporate alarm vcrilieation .
Alarm verification sci for seconds
181 This system docs not incorporate pre-signal.
181 This system docs not incorporate PAS.
l8l This system docs not have other initiating devices.
6. SUPERVISORY SIGNAL-INITIATING DEVICES
6.1 Sprinkler System Supervisory Devices
'I y pe and number of devices: Addressable: 2
Other (specil} ):
6.2 Fire rump Description 11nd Supervisory Devices
Type lire pump: 0 Electric pump 0 Engine
Type and number of devices: Addressable:
Other (specify):
6 .2.1 Fire rump Functions Supervised
0 This system docs not ha ve sprinkler supervisory devices.
Conventional: Coded; fomsmit11:r:
181 This system docs not have a lire pump.
Conventional: Coded: Transmitter:
0 Power 0 Running 0 Phase reversal 0 Selector switch not in auto 0 Engine or control panel trouble 0 Low IUcl
Other (specify):
6.3 Duct Smoke Detectors (DSDs)
Type und number of devices: Addressable;
Other (specif}'):
Type of coverage:
181 This system docs not have DSDs causing supervisory signals.
Conventional:
Type of smoke detector sensing technology : 0 Ioni zation 0 Photoelectric 0 Aspirnting 0 llcam
6.4 Other Supervisory Devices
()..:scribe;
!81 This sysh:m docs not have other supervisory d..:viccs .
Copy11ght C 2009 National Fwe Protedooo Associalion Ths rorm may be copied for individual u se olher than for resale tt may not be eopoed for commetcial sate or dlstnllulion
7. MONITORED SYSTEMS
7.1 Engine-Driven Generator 181 lhis system docs not have a 1?1m c rnlor.
7.1.1 Generator FuncCions Supervised
0 Engine or control panel trouble
0 Other (specify):
0 Gcncrnlor running 0 Selector switch not in auto 0 Low It.cl
7.2 Spccial llaz:1rd Suppression Systems
Description of special hawrd systcm(s):
7.3 Other Monitoring Systems
Description of special hai'.anl systcm(sl:
8. ANNUNCI ATORS
8.1 Location 11nd Description or Annunciiitors
Loeation I :
Location 2 :
Location 3:
9. ALARM NOTIFICATION APPLIANCES
181 This system docs not monitor special hazartl system:..
181 This system docs no l monitor other systems.
181 This system docs nol have a nnunciators.
9.1 ln·Building Fire Emergency Voice Ah1rm Communicntion System 181 This system docs not have an EV ACS.
Number o f single voice alarm channels: Number o l' multip le voice a larm channels:
Number of speakers: Nu mber or s peaker circuits:
1.ocatiun uf amrlilication and sound-proci..-:;sing equipment:
Location of paging microphone stations:
I .ocation I :
I .ocation 2 :
Location .l:
9.2 Nonvoicc Notification Applin11ces O This system d oc s not have nonvoice nol ilicatio n appliances .
I lorns: W ith visi ble: 28 13ells: Wi,th visible;
Chimes: With visible:
Vi sible only: 6 Other (tlcscribe);
9.J Notilic:1tion Appliance Power Extender P:mels 0 This system docs not have power extender panel s.
Quantity: 1 FCPS
Locations: In IT/DATA ROOM
Copyflghl O 2009 No>ba<lal Fwe PrOledoon AsS0C1atioo This f0tm may be copted for oodrv>dual use Olher th<ln f0< 1esllkl It may nol be copied for commorc1a1 salo or distribut on
7. MONITORED SYSTEMS
7.1 Engine-Driven Generator
7.1.1 Generator Functions Supervised
0 Engine or conlrol panel trouble 0 Gcncrnlor running
0 Other (s pecily):
7.2 Special llnzard Suppression Systems
Description of special halllrd systcm(s):
7.3 Other Monitoring Systems
Description of special hazard systcm(s):
8. ANNUNCIATORS
8.1 Locntion and Description or Annunciators
Location I :
Localion 2:
Location 3 :
9. ALARM NOTIFICATION APPLIANCES
r81 Thi s sy slcm docs no! have a generator.
0 Selector switch not in auto 0 Low fuel
181 Thi s sy1item doc s not monitor special hazard systems.
181 Thi s syslcm docs not monitor other systems.
[8] Thi s system docs not have annunciators.
9.1 In-Building Fire Emergency Voice Alarm Communication System 181 This system docs no t have an EV ACS.
Number of sin gle voice alann channels: Number of multiple voice alarm channels:
Number or speaker.;: Number of speaker circuits :
Location or amplilication and sound-processing equipment:
Location or paging microphone stations:
Location I:
Location 2:
Location 3:
9.2 Nonvoice Notificntion Appliances D This system docs not lrnvc nonvoicc notification appliances .
llorns: With visible : 28 Bells: With visible:
Chimes: With visible:
Visible only: 6 Other (describe):
9.J Notification Appliance Power Extender Panels D This system docs not have power extender panel s.
Quantity: 1 FCPS
Locations: In IT/DATA ROOM
, I I
Copyright C 2009 NellOnal Fite PtoCecttOn AsSOClation. This fonn may be c:opoed lot individual use other I/Ian lor tesa/e. tt may not be coped for commercial sale or dtstnbution
10. MASS NOTIFICATION CONTROLS, APPLIANCES, AND CIRCUITS C8I This system docs not have an MNS.
I0.1 MNS Locnl Operating Consoles
Location I:
Location 2:
Location 3:
10.2 High-Power Spenker Arrnys
Number of I IPSA speaker initiation zones :
Location I:
Location 2:
Location 3:
I0.3 Mnss Notification Devices
Combination fire alarm/MNS vi sible appliances:
Textual signs: Other (describe):
Supervision class:
I 0.3.1 Special l-111znrd Notilicntion
MNS-only visible appliances:
~This S)stcm docs not have special suppression predischargc notification.
0 MNS systems DO NOT override nutilication appliances required to provide special suppress ion
prcdischarge noti lication.
11. TWO-WAY EMERGENCY COMMUNICATION SYSTEMS
I I .I Telephone System 18] 111is system docs not have a two-w ay telephone system .
Number of telephone j ad.~ installed: Number of warden stations installed:
Number of telephone handsets stored on site:
Type of telephone system installed: 0 Electrically powered 0 Sound powered
11.2 Two-Way Radio Communications Enhancement System
~ This sy stem docs not have a two-way radio communications enhancement system.
Percentage of area covered by two-way md io servicc: Critical areas : % General building nrcas: %
Amplilication component loca1ions :
Inbound signal ~tn:ngth : dBm Outbound signal strength: dUm
Donor antenna iso lation is: dB above the signal booster gain
Radio frequcneil.-S covered :
Radio system mon itor panel locution :
Copyt1gllt C 2009 Nat.onal Fite Protection Assoc1&t1on This form may be copied 10< indivGial use other 11\an f0t resale II may not be c:cp:ed for commewal salo ot dislnbutlOll
11. TWO-WAY EMERGENCY COMMUNICATION SYSTEMS (continued)
11.3 Arca of Refuge (Arca of Rescue Assistance) Emergency Communications Systems
l8l "l l1is system docs not have un area ofrcfogc (urea of rescue assistancc) emergency communication s system .
Number of stat ions: Location of central control point
Days and hours \~hen central con1rol point is attended:
I .<lcation of a llcrnalc control point:
Dnys :11111 hours when alterna1e control point is attended :
11.4 Elevator Emergency Communicntions Systems
18l "ll1is system docs not have an cle\rator emc rgcncy co mmu n icat ions system .
Number or elevators with stations:
Days and hours when central control point is attended:
I .o~:ation of alternate control point:
Days and hours when alternate control point is aucndcd :
11.5 Other Two-Way Communication Systems
Dc.-scrihc :
12. CONTROL FUNCTIONS
·1 his system act ivates lhc follow ing control foc t ions :
Location of central conlrol point :
0 I lo ld·open door releasing dcv icL"S D Smoke management 0 I IV J\C shutdown 0 FIS dampe rs
0 Door unlocking 0 l:leva tor recall 0 Fuel source shutdown 0 Extin guishing ugcnt relea se
0 Elevator shunt trip 0 Ma..;s notilication system override of lire alarm notification appl ianeL"S
Other (specify): Fa ll Shutdown & Furnace Shutdown
12.J Addrcss11ble Control Modules
Numhcr of <lcviccs:
Other (spcciry):
13. SYSTEM POWER
13.1 Control Unit
13.1 .1 Primary Power
Input voltage ofctlll trol panel : 120 VAC
<hercurrent protcc1ion : Ty pe : CIRCUIT BREAKER
Location (of primary supply panel hoard): IN FACP
Disconnecting means locution : CIRCUIT BREAKER
13.1.2 Engine-Driven Generator
Locat ion or generator:
Lociltion of lite! st orage :
l8l This sys tcm docs not have cont rol mud ul1."S.
Contro l panel amps : <20
J\mps: 20
£8) "I his system docs no t have a generat or.
Type of foci :
~I 0 2009 tialJO<lal Frc PtOlectlOrl A$$oclahoo Tlws lotm may be cop104 for 1ndrvl(lual us. other 1han lot 1&$ala II may not be copied for commercial sate 0< d1st11btlt100
11. TWO-WAY EMERGENCY COMMUNICATION SYSTEMS (continued)
11.J Arca orRcrugc (Are:1 or Rescue Assist:1ncc) Emergency Communications Systems
[81 This system docs not have an area of refuge (area of rescue assistance) emergency communications system.
Number of stations: Location of central control point:
Days and hours when central control point is attended:
Locntion of allcmate control point
Days and hours when alternate control point is attended:
11.4 Elcvntor Emergency Communications Systems
[81 This system docs not have an elevator emergency communications system.
Number or elevators with stations: Location of centml control point:
Days and hours when central control point is attended :
I .ocation of alternate control point:
Days and hours when alternate control point is attended:
11.5 Other Two-Wny Communication Systems
Describe:
12. CONTROL FUNCTIONS
This system activates the following control fuctions :
0 1 lold-opcn door releasing devices 0 Smoke management 0 I IV AC shutdown 0 FIS dampers
0 Door unlocking 0 Elevator recall 0 Fuel source shutdown 0 Extinguishing agent release
0 Elevator shunt trip D Mass notification system override or lire alann notification appliances
Other (5pecily): Fan Shutdown & Furnace Shutdown
12.1 Addressable Control Modules
Number of devices:
Other (specify):
13. SYSTEM POWER
13.1 Control Unit
13.1.1 rrimnry Power
Input volla~e of control panel : 120 VAC
Ovcrcurrcnt protection : Type : CIRCUIT BREAKER
Locat ion (of primary supply panel board}: IN FACP
Disconnecting mean s location: CIRCUIT BREAKER
13.J.2 Engine-Driven Generator
Local ion of ~cneralor :
Locat ion of fuel stornge :
£81 Th is system docs not have control modules.
Control panel amps : <20
Amps: 20
(81 This system docs not have a generator.
Type of foci :
Copyright 0 2009 National Fire Protec11on AssOCJatoon This form may be cop10<1l0<1nd1v1duel use other than for resale It may nol be copied for commercial sale 0< d1slnbullon .
13. SYSTEM POWER (continued)
13.1.3 Uninterruptible Power System
Equipment powered by a UPS system;
Location of UPS system:
[8J This system docs no! have a UPS .
Calculated capacity of UPS batteries to drive the syslcm components conncclcd to it:
In slandhy mode (hours):
13.1.4 Batteries
Location : IN FACP Type: Sealed
Lead Acid
Culculalcd capacily of batteries to drive the system:
In standby mode (hours): 24 HOURS
In alarm mode (minules):
Nominal voltage: 24VDC Amp/hour rating :
In alarm mode (minutes): 5 MIN
[8J Batteries arc marked with dale of manufacture 0 Battery calculations arc attaclu.:d
13.2 In-Building Fire Emergency Voice Alnrm Communication System or Mass Notilicntion System
[8J This syslcm docs not have an EV ACS or MNS system.
13.2.1 Primary rower
Input voltage of EV ACS or MNS panel: EV ACS or MNS panel amps:
Ovcrcum:nt protection : Type: Amps:
Location (of primary supply panel board):
Disconnecting means location:
18 Ahr
13.2.2 Engine-Driven Generator
Local ion of gcncrntor:
l8J l'his syslc.:m doc s not have a generator.
Location of fuel storage:
13.2 .3 Unintcrruptiblc Power System
Equipmenl powered by a UPS system:
Location of UPS system:
fypc.: of fuel :
[8J This system docs not lrnvc a UPS .
Calculated capacity of UPS batteries to dri ve the syslcm components connected to it:
In standby mode.: (hours):
13.2.4 Batteries
Location: Type:
Calculated capacity of batteries to drive the sys tem :
In slandhy mode (hours):
0 Batteries arc marked with dale of manufaclu rc
In alarm mode (minutes):
Nominal voltage :
Jn alam1 mode (minulcs):
0 Battery calcul:uions arc attached
Amp/hour rating :
Copyright e 2009 National F~e Pt0tec1ion Associat1Ctt This form may be copied for llld1vldual use oO>er lhan lot resale II may not oe COpted for commeraat sale or cstrlbul1on
13. SYSTEM POWER (continued)
13.3 Notification Applfance Power Ex tender Panels 0 Thi s system docs not have power extender pan -.:l s.
13.J.I Primary Power
In put voltage o f power ex tender pancl(s ): 120 VAC J•owc r ext ender panel amps: >20AMPS
Ovcrcurrc nl prot ection : Type: CIRCUIT BREAKER Amps : 20 AMPS
Location (of primary supply punc l board): Electrica l Room
Disconnci:ti ng means location: Eledrica l Room
13.J.2 Engine-Driven Generato r f8) I hi s sys tem docs not ha ve a gcncr.1l<>t.
Location of generator:
Location o r foci stomg c: Type of fuel :
13.3.3 Uninter rupti bl c Powe r System
E~uipmcnt powe red by a UPS sys tem:
f8) 1 his sys tem docs not have i i UP S.
Location of UPS system:
Calcu lated capacity oflJl'S hallerics 10 drive the sys1em compnncnts connected lo it :
In standby mode (hours):
13.3.4 Batteries
Locat ion : IN CABINET Type : Sealed
Lead Acid
Calculmcd capadly of batteries lo drive the i.ystcm :
In ala nn mode (mi nutes ):
Nomin al vo lt age: 24VDC Amp/hour rating :
I n stan dby mode (hours ): 24 HOURS
f8I Ball er ics :ire mar~cd ~vil h date o f manufacture
In alarm mode (minutes)! 5 MIN
0 Uatlcry calcu lations arc allachcd
14. RECORD OF SYSTEM tNSTAL LATION
/·ill mil t l}i er all i11stullatio 11 is complete a11d wiring ltas becJ11 c/1eckt:d j (1r opens. slt orls , gro11mlji111lts, mu/ improper
lm 111d11'11g, /mt beji>rl! cmu/11 cti11g opt:rutional accep11111ce tests.
Thi s is a : f8) New sys tem 0 Modificati on to an exi sting sy stem l'cnni t number :
The sy stem has been insllllled in accordance with the following requ irements: (Note any or all th at appl y.)
f8) Nfl'tl 72. Editi on: 2010
181 NF />,/ 70. Na1io11al /~"lectrical Ct>dc!. Arliclc 760. J:dition :
181 Manufaciurcr 's published instruction s
Othe r (speci fy):
75Alu
::.::~~:·:/f Z2"A ,.,.d .. :: .. ,00 .,,.,. ·~" ~""
o • .,.,;,";,9 cl I 1 rnk• svsTEMs TECHNICIAN
Date : 1117/2016
l'hooe: 9 70-241 ·0268
Copyogl>l O 2009 Nntional f •o PrOlectoon AsSOC1at1on This fOfm may bo coi>«I for 1nd1vidual use o ther th:in for reSllle_ II may not be copiod IOI commorc1al sale o.-d1st ribut 1on
13. SYSTEM POWER (continued)
13.J Notification Applinnce Power Extender Panels 0 This system docs not have power extender panels.
13.3.1 Primnry Power
Input voltage of power extender p:mel(s): t20 VAC Power extender panel amps: >20AMPS
Ovcreurrenl protection: Type: CIRCUIT BREAKER Amps: 20 AMPS
Location (of primary supply panel board): Electrical Room
Disconnecting means location: Electrical Room
13.3.? Engine-Driven Generator IZI This syslem docs not have a generalor.
Locntion of generator:
Location or fuel storage: Type of fuel:
13.3.3 Unintcrruptible Power System
E9uipment powered by a UPS system:
181 This system docs not have a UPS.
Location of UPS system:
Calculaled capacity of UPS batteries to drive the system components connected to it:
In standby mode (hours):
IJ.J.4 Batteries
Location: IN CABINET Type: Sealed
Lead Acid
Calculated capacity of batteries 10 drive the system:
In alarm mode (minutes):
Nominal voltage: 24VOC Amp/hour rating:
In standby mode (hours): 24 HOURS
181 Dattcrics arc marked with date of manufacture
In alarm mode (minutes): 5 MIN
0 Battery calculations arc attached
14. RECORD OF SYSTEM INSTALLATION
Fill out afler all installation 1s complete and wiri11g lra:r berm clu:ckcd for opc11:r. shorts, ground faults, w1d improper
bra11d1i11g, but beforl! co11ducti11g operational acceptance tests
'fl1is is a: 18] New system 0 Modification to an exi sting system Permit number:
The system has been installed in accordance with the following requirements: (Note any or all that apply.)
181 NFJ>A 72. Edition: 2010
181 NFJ>,1 70, National Electrical Code. Article 760. Edition :
[81 Manufacturer's published inslruclions
Other (specify):
7 5Ahr
s;gn<J',ff-?-. J-../ p,;occd "'m" Bot<h M<N•y
System deviations fi/;om re~rcJcd1NJ7PA standards :
Organizali9 C Tille: SYSTEMS TECHNICIAN
Date: 111712016
Phone: 970·241-0268
I ' 1 1F
Copynghl C> 2009 Nollonal Fite Protec:lion Associalion This loon may be copied for ind1v1dual use Olhet lllan for resale II may not be copied lot commercool sale or dislrbutoon
15. RECORD OF SYSTEM OPERATIONAL ACCEPTANCE TEST
[8J New system
All operatio11al/eat11res a11df11nctio11s of this system were tested by. or in the presence of the signer s/1ow11
below, 011 t/1e date shown below, and were found lo be operating propcr(1 1 in accordance wit Ir tire requirements
for the jollowi11g ·
D Modilications to an existing S) stem
,/// new~11 modified operatio11alfea111res c111dfi111 c11011s of the system were tested by. or in tl1e presence of tire
signer shown below, 0 11 thc date shown below. and were found to be operating properly ill accordance with tire
rc?q11irc?mellfs of the following :
[8J N Fl'il 72, Edition: 2010
D NFP:I 70. National Electrical Code, Article 760. Edition :
0 Manufacturer's published instructions
O:her (specily):
s;,oou: ~ : ' /.,./ p,;n"d oom" B""" MoNoy Oot" 111712016
0 Individual devic1.:7t · ~1um1· ation I Inspection and Testing Form (Figure 14.6.2.4) is attached!
Organi7.atio!V' C t I itle: Operations Manager Phone: 970-241-0268
16. CERTIFICATIONS AND APPROVALS
16.1 System lnsh1ll11tion Contrnctor:
This system. ~s speci/97zei . ms been installed and tes ted according to all N FPA s tandards cited herein. s;"""'~~ -f , , I Pdmc ... oom" ""''" MoN•y o,," 111712016
Orga11ization7 CSt ~ Title : Operations Manager Phone: 970-241·0268
16.2 System Service Contrnctor:
The undersigned has n;ervt c1tract I' lhi s system in effect ns of the date shown below.
Signed : ~ ~ r ~ l'rinlcd name : Butch McNay Organi 7.atio~ CSt Title: Operations Manager
Date: 1117/2016
Phone: 9 70-241 ·0268
16.3 Supervising Stntion :
':'.is S)s~tem. ·rr:7·ne ere/wit/I be monitored according to all Nr-PA standard s cited he rein .
Signed: .. ~ l'rin1ed name: Butch McNay
Orga niz atio : C Title: Operations Manager
Date: 1117/2016
Phone: 970 -241-0268
Copynghl 0 2009 NatlO<Ult Fote ProlecloOn A$sociahon This f01m may be copied la< ind!Vldual use other than for resale II may not bo copied for commercial sate or dtstnllutlOn
16. CERTIFICATIONS AND APPROVALS (continued)
16.4 Properly or Owner Representative:
I uccept this system as having been installed and tested to its specificatio ns and all NFPA standard ~ cited h1..'Tei n.
Signed : /~-4rq ~
Organi? .. ali on: 7l:::~ )<.,.,
16.5 Authority Having .Jurisdiction:
rrinted name : 77/~rvrs C-<>uk.
Till e : VI°
Dale : lf/1'1}16
Phonc{3v?} ~; --~ptr:f
I have witnessed a s:11islhc1ory acceptance lest of thi s sys lem and lind ii to be installed and operat ing properly
in accordance with •ts approved plans and speci tications. wilh its approved sequence of ope rati on s. and wi th ull
N FP A slilnd an ls <:ited herei n.
Pri nted name:(!}~ 0, ,,-......_ Dale: t/h9"/Jt-
Tit le : U.ti ;1.Jt],,,Ji-/ ~;v/h~·1rme : tZ.S--/2if3
Copyr1gt>1C2009 Nntoonat f•o Proeection Assoantion Thi s lonn m:ly be cop.eel'°' indiVldual uso other thOlll lot resalo II may not bO copied lot a>mmerc1a1 sate or d1strobut1on
16. CERTIFICATIONS AND APPROVALS (continued)
16.4 rropcrty or Owner Rcprcscntntivc:
I accept this system as having been installed and tested to its specifications and all NFPA standards cited herein.
Signed: /~,_ 44 ~
Organization: Tu~J'-'
J6.5 Authority I l:lving Jurisdiction:
Printed name: /7{::;1f1Vi5 C,,.ouk.
Title: VI°
Date: lt/11/16
Phone:(~?) ~] ~~f-!CI.
I have witnessed a sati s factory acceptance lest of this system and lind it lo be installed and operating properly
in accordance with its opprovcd plans and spccilication s. with its approved sequence of opcr.itions, and with all
NFPA standards cited herein .
Printed name: ()~ ~) ~ Date: t/ h'l/J/,
Title: -:U." l ;,..J t),,,,J-/ fi7 :v lhl1a&~-1'rmc: t 2-S"-/2£/3
, ,f< I ' I.: f .1 1 I ) I\ ,' 1
Copyright O 2009 NatlOlleJ Firo ProtecttOn Association This lonn may be copied for ondivodual use other than for resale II may no1 be copied for commercial sale or doslrlbution