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INSPECTION AND TESTING FORM 0 (- 7109 /
DATE: C} III ItJ!
TIME: -:S:.tOPII1
SERVICE O~~TION . L'_ PROPERTYj!AME (U~~R)
NAME J.,eW\C~ f0~ ::YFrery NAME: r-/V&- ff.lf1V;5
ADDRESS: /<601 7~.n.. S7. e. ADDRESS:
REPRESENTATIVE: IJe,vIV,/ fJ.,KlL. OWNER CONTACT: j/~ 1
LICENSE NO.: 1ELEPHONE: >17 /......- ?
1ELEPHONE: q5} ~~rs3-.;u:,oO . ) /'
MONITORING E1'llll " . 'A:A__... J /'_ APPROVING AGENCY
CONTACT; ::.r,.,f/J:1'Jft'It'1J~"'.ft. ~ (.,rtaIt!Tl CONTACT:
TELEPHONE: (IAl.,) f:>1) - ~'Y( ~ '6~-I.Q. TELEPHONE:
MONIIUNNG ACCOUNT REF. NO.: Cjo I ( 'I.?)
TYPE TRANSMISSION
[ ] - McCulloh
[ ] - Multiplex
~- Digital
[ ] - Reverse Priority
[ ]-RF
[ ] - Other (Specify
~~~y'
,
&, tyl;t(37
'-/'17 ..,~~.
,
SERVICE
[ ] - Weekly
[ ] - Monthly
[ ] - Quarterly
[ ] - Semi-Annually
~ - Annually
[ ] -Other (Specify)
PANELMANUFACTURER: S~t'-n:s MODEL NO.: M;{L-- T G{
CIRCUITS1YLES: <)tl-' C-l.JillSS 13 - S7'l~ '3 '"'~- ?' ,t1n( "v-+c- ,I!J~~ S
NO. OF CIRCUITS: ~ c; J.. ~ - d- N A-l_ - C-1...A5:J 8 '57 Y lifE W
Sur l\VARE REV.: YM /~. () "3 (' ~ G,1Y'l I. . /
LASTDA1E SYS1EMHADANY SERVICE PERFORMED: ~ (If It; / J /
LASTDA1E mAT ANY SOFTWARE OR CONFIGURATION WAS REVISED: q / /~ /61
,
ALARM INIT A TlNG DEVICES AND CIRCUIT INFORMATION
QTY3F
7~
'/9
S
9
<I
CIRCUIT STYLE (,~~ 8
'5
~
i
:5
MANUAL STATIONS
ION DE1ECTORS
PHOTO DETECTORS
DUCT DETECTORS
HEAT DE1ECTORS
WA1ERFLOW SWITCHES
SUPERVISORY SWITCHES
OTHER: (SPECIFY)
ALARM NOTIFICATION APPLIANCES AND CIRCUIT INFORMATION
QTY OF
.tt'IS
CIRCUIT STYLE
W ~,A~~LL3
Wo~'U ~',,'".
NO. OF ALARM NOTIFICATION APPLIANCE CIRCUITS:
ARE CIRCUITS SUPERVISED? P(VES [] NO
J
a Hfo.IES
tJ -I J\.u'b~~
~ L...u...c~
b 1 rlLtl..-tSPEcWY)
;;) N" c.... CLIX5.t> S-ry l € hi
QTY OF
SUPERVISORY SIGNAL INITIATING DEVICES AND CIRCUIT INFORMATION
CIRCUIT STYLE
2
BUILDING TEMP
sm WATER TEMP
sm WATER LEVEL
FIRE PUMP POWER
FIRE PUMP RUNNING
FIRE PUMP AUTO POSmON
FIRE PUMP OR PUMP CONIROLLER 1ROUBLE
GENERATOR IN AUTO POSITION
GENERATOR OR CONIROLLER 1ROUBLE
SWITCH 1RAN:s1' bK
GENERA lOR ENGINE RUNNING
OlliER: (SPECIFY)
SIGNALING LINE CIRCUITS
Ql-';';~I and style (See NFP A 72, Table 3-6) of signaling line circuits connected to system:
Quantity q Style(s), ":?
SYSTEM POWER SUPPLIES
a P.:....""! (Main): Nominal Voltage
\
\
Overa...wu. P."';';'~: Type
;:>:1 (/ I) L ,Amps
,Amps
t
Location (Panel Nwnber): n XL -Z"61
Disconnecting Means Location:
b. Seconda1y (Standby):
t:) -1ri. V Storage~j: Amp-HrRating ::S~-j!J
Calculated capacity to +...~ system, in hours: 24 60
Engine-driven gen...~. dedi~ to fire alann system:
Location offuel storage: 1'/,/ A--
TYPE BATfERY
[] Dry Cell
[] Nickel Cadmiwil
~ Sealed Lead-Acid
[] Lead-Acid r: ~. A.. ')
/ - I? 1/ ,.........,. ~~/ P'A /1/ /K. ,A--..ez<;
[] Other (S....."irj) .I:? cr I'~' If" rw-
c. Emett~ or standby system used as a ~ to prima1y ~wer supply, instead of using a seconda1y power supply:
r-.. Em...",....cy system descnbed m NFPA 70, Article 700
Legally required standby descnbed in NFPA 70, Article 701
Optional standby system descnbed in NFP A 70, Article 702,which also meets the perfonnance
requirements of Article 700 or 70 I.
PRIOR TO ANY TESTING
NO .....CATIONS ARE MADE: YES NO
MONITORING ENTITY P<f [ ]
BUILDING OCCUPANTS [ ] [ ]
BUILDING MANAGEMENT [ ] [ ]
01HER (SPECIFY) [ ] [ ]
AHJ (NOlltU::;D)OF ANY IMPAIRMENTS [ ] [ ]
SYSTEM TESTS AND INSPECfIONS
VISUAL FUNCfIONAL
[)<(
~
txl
[)<
t)4
[)4
~
~
[ ]
INITIATING AND SUPERVISORY DEVICE TESTS AND INSPECTIONS
DEVICE VISUAL FUNCTIONAL FACTORY MEAS.
TYPE CHECK TEST SETTING SETTING
TYPE
CONTROL PANEL
ThlI tKF ACE EQUIPMENT
LAMPS/LEDS
FUSES
PRIMARY POWER SUPPLY
TROUBLE SIGNALS
DISCONNECT SWITCHES
GROUND FAULT MONITORING
SECONDARY POWER
TYPE
BA lInK i CONDmON
LOAD VOLTAGE
DISCHARGE lEST
CHARGER lEST
SPECIFIC ORA VITY
TRANSIENT SUPPRESSORS
REMOlE ANNUNCIATORS
NO .....CATlON APPUANCES
AUDIBLE
VISIBLE
SPEAKERS r'11t
VOICE CLARITY III JIfr
LOC. & SIN
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
VISUAL
[ ]
FUNCfIONAL
~
~
[ ]
3
WHO TIME
::rzx.
COMMENTS
COMMENTS
/Ill- ~....., IVI2W
/1z '- ~ Iv '5 <:evY~",?
_~/) ~ J..,/I G--
PASS FAIL
[ ] [ ]
[ ] [ ]
[ ] [ ]
[ ] [ ]
[ ] [ ]
[ ] [ ]
[] []
[] []
[] []
[] []
[] []
[] []
4 vY-+-~-nR'c~ A?v/) ?' ,..",.,.,#t''1'Z ~ C .t5t;JI'c/ )
AzL Ovc-r LJ~e~s 17 d,-t."'tr4 "~,r. -'f-:r ~~"" "'..cy
~L ~. -- 6ccLJ .b. 8. q //"'7 f!':l./ '
/ ' If' -,
COMMENTS:
~, _.___~,_._ _t/.
VISUAL FUNCTIONAL COMMENTS 4
EMERGENCY COMMUNICATIONS
EQUIPMENT
PHONE SETS [ r!r [ ]
PHONE JACKS [ [ ]
OFF-HOOK INDICATOR [ [ ]
. AMPLIFIER(S) [ [ ]
TONE GENERA TOR(S) [ [ ]
CALL IN SIGNAL [ ] [ ]
SYSTEM PERFORMANCE [ ] [ ]
VISUAL
INTERFACE EQUIPMENT
(SPECIFY) ;:J I CNV'I'7#t.. ~et~
(SPECIFY)
(SPECIFY)
SPECIAL HAZARD SYSTEMS
(SPECIFY)
(SPECIFY)
(SPECIFY) [ ] [ ] [ ]
SPE...{:I~L PROCEDU~:.. _ ..If _ _ ./-' ~ ) /' '.1: \
".;.<1 ~ ~A-)'S~ ~~~#/fr;.,~~ (I /V~ ~ /7Pt- (.A'/~S.{ 7.J
I;S7 FAN ~~~/.. ~d..2 "'N~ I/AI/t5 ~7 J .? Ft'"~ ttlv~ ~~~ INe1""V~
COMMENTS: ~/;J 2 "A"Jp__/4~"..G, ~/;,.~ A-t..A7 I "'1'i1L~vdl. ~ ~ S v~ -"';....c...y .
Ch'?';/ #t.~ "'~v4u. (&""'~;I-?":5 A'U"h/k~ <:IN JC:...('-~ ~<tf!'-~[A'~Y
c.GNrne~,=> ~d 2,-'V~ H"7 Tn;# r'- f'AJ.4l. ?1 /0 ~ h'1
;
ON/OFF PREMISES MONITORING:: YES NO TIME
ALARM SIGNAL ~ [ ]
MMW~SroML / [ ]
TROUBLE SIGNAL [ ]
TROUBLE RESroML .r:. [ ]
SUPERVISORY SIGNAL [ ]
SUPERVISORY RESroML [ ]
DEVICE
OPERATION
SIMULATED
OPERATION
1<t
[ ]
Iv Iff
COMMENTS
NO. II' .CATIONS THAT TESTING:
IS COMPLETE YES
BUILDING MANAGEMENT ~]]
MOl'll I uKlNG AGENCY
BUILDING OCCUPANTS
OTHER (SPECIFY) [ ]
THE FOLLOWING DID NOT OPERATE CORRECTLY:
NO
WHO
TIME
I I
SYSTEM RESTORED TO NORM1L OI?,RA TI~) DA~E 91/~/tt I TIME
THIS TESTING W AS PE'F~. i~. ~E WITH APPLICAB,LE NFPA ST ANV!IDs..... fi' () /., }
NAMEOFINSl}I?CYb: v: f~/? /Y-,\- 9~~7~A~'7117/~1
DATE: ., /17 rei y '1-IME: q.'a; J'.IS'1
r
SIGNA TURE:
NAME OF O~E~OR REPRESENTATIVE. :
DATE: -'/11 /~ / ~,-.." TIME: L/:tt:P/YJ
SIGNATURE: V~ h r1 V I r h 7"""'Y1
. , ""
Reprinted with pennission from NFPA 72. National Fire Alarm Code, Copyright <<:)1996, National Fire Protection Association, Quincy, MA 02269.
This reprinted material is not the complete and official position of the National Fire Protection Association, on the referenced subject which is
represented only by the standard in its entirety.
Distributed by: AFAA - P.O. Box 951807 - Lake Mary, FL 32795-1807 - (407) 322-6288 - (407) 322-7488 fax
. //