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Home My WebLink AboutFIRE ALARM COMPLETION REPORT - 20-00063 - Madison Memorial Medical Clinic RemodelSYSTEM 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: Aug 5 2020 Supplemental Pages Attached: 1. PROPERTY INFORMATION Name of property: Madison Mem Hosp Address: 450 E Main Description of property: hosp Name of property representative: Madison Hosp Address: Same Phone: Fax: E-mail: 2. INSTALLATION, SERVICE, TESTING, AND MONITORING INFORMATION Installation contractor: JCI Fire Protection Services Address: 8783 W HACKAMORE DR, STE 6 BOISE, ID 83709 Phone: Fax: E-mail: Service organization: JCI Fire Protection Services Address: 8783 W HACKAMORE DR, STE 6 BOISE, ID 83709 Phone: Fax: E-mail: Testing organization: JCI Fire Protection Services Address: 8783 W HACKAMORE DR, STE 6 BOISE, ID 83709 Phone: Fax: E-mail: Effective date for test and inspection contract: Monitoring organization: JCI Fire Protection Services (SIMPLEX) Address: 8783 W HACKAMORE DR, STE 6 BOISE, ID 83709 Phone: 509-534-6055 Fax: E-mail: Account number: Phone line 1: Phone line 2: Means of transmission: Entity to which alarms are retransmitted: Phone: 3. DOCUMENTATION On-site location of the required record documents and site-specific software: FACP 4. DESCRIPTION OF SYSTEM OR SERVICE This is a: ❑ New system ® Modification to existing system Permit number: FIR2020-00063 NFPA 72 edition: 2017 4.1 Control Unit Manufacturer: Simplex Model number: 41 00e 4.2 Software and Firmware Firmware revision number: 12.05.03 4.3 Alarm Verification Number of devices subject to alarm verification: ® This system does not incorporate alarm verification. Alarm verification set for seconds Copyright 0 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. SYSTEM RECORD OF COMPLETION (continued) S. SYSTEM POWER 5.1 Control Unit 5.1.1 Primary Power Input voltage of control panel: 122 VAC Overcurrent protection: Type: BREAKER Branch circuit disconnecting means location: 5.1.2 Secondary Power Type of secondary power: BATTERY Location, if remote from the plant: Calculated capacity of secondary power to drive the system: In standby mode (hours): 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 Control panel amps: Amps: 20 Number: In alarm mode (minutes): 8 Pathway Type Dual Media Pathway Separate Pathway Class Survivability Level Signaling Line Device Power B Initiating Device B Notification Appliance B Other (specify): 7. REMOTE ANNUNCIATORS Type Location N'a 8. INITIATING DEVICES Addressable or Type Quantity Conventional Alarm or Supervisory Sensing Technology Manual Pull Stations n/a Smoke Detectors 7 Adressable Alarm photo Duct Smoke Detectors n/a Heat Detectors n/a Gas Detectors n/a Waterflow Switches n/a Tamper Switches n/a Copyright 0 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. SYSTEM RECORD OF COMPLETION (continued) NOTIFICATION APPLIANCES Audible n/a Visible 12 4906-9104 Combination Audible and Visible 8 4906-9130 10. SYSTEM CONTROL FUNCTIONS Hold -Open Door Releasing Devices HVAC Shutdown Fire/Smoke Dampers Door Unlocking Elevator Recall Elevator Shunt Trin 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 if, qm has been installed according to all NFPA standards cited herein. Signed: Printed name: Mark E. McMillan i Organization: JCI Title: SRTR 12.2 System Operational Test This system as ifie h e has tested according to all NFPA standards cited herein. Signed: Printed name: Mark E. McMillan Organization: JCI Title: stsr 12.3 Acceptance Test Date and time of acceptance test: Installing contractor r— Testing contractor rep Property representativ AHJ representative: ..September 2020 1200am Qua N/A N/A N/A N/A N/A Date: 9-9-2020 Phone: 509-994-1590 Date: 9-9-2020 Phone: 509-994- 1590 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.