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32A-088 GANDARA CENTER COI 09/04/2024 The Commonwealth of Massachusetts , 4 • City of Northampton �, bey. .�7• New and Renewal Certificate of Inspection In accordance to 780 CMR Chapter 1 (The Ninth Edition of the Building Code) and Chapter 110 and the Acts of 2004, to further enhance fire and life safety, this certificate of inspection is issued to the premise or structure or part there as herein identified. Issued to Identify Name of Establishment: Certificate No. GANDARA CENTER 0036 Located at Identify property address including street number, name city or town and county Certificate Expiration 25 GRAVES AVE, Northampton 08/13/2025 32A-088-001 Use Group Classifications Allowable Occupant Load R — 3 16 Residents 6 Staff This certificate of inspection is hereby issued by the undersigned to certify that the premise,structure or portion thereof as herein specified has been inspected for general fire and life safety features.This certificate shall be framed behind clear glass and/or laminated and posted in a conspicuous place within the space as directed by the undersigned. Failure to post or tampering with the contents of the certificate is strictly prohibited. Name of Municipal Name of Municipal Date of Fire Chief Building Inspector Kevin Ross Inspection 09/04/2024 Signature of Signature of Municipal Fire Municipal //47 Chief Building Inspector Date of Issuance 09/13/2024 City of Northampton ' � �� Massachusetts \ ::,. ::..66": <\rt( I t(3 ��ri4DEPARTMENT OF $UII.DINC� INSPECTIONS1 `y1,. ,5 212 Main street • Municipal eu ding . ^O�b. ��"-� Northampton, MA 01060^T Op �Q4, bi ..,�.. PERIODIC INSPECTIONS 1OgTyg0/z0/ TON lia�Nso PREMISE NAME: GANDARA CENTER MAO°607ONs r ,n PREMISE ADDRESS: OWNER(S) OF RECORD: - , .., d f.j, itilili /ii5iu•- OWNERS: ADDRESS: ST: TELEPHONE NO: • -� _ 1.: 7 .5,. l 9 LW,Pf,.0�1,0 ..! ✓.. S (ien/i.' pivot "t/1 - o f'.0.9 NAME ON CERTIFICATE: TYPE OF BUSINESS /�'_� f ./ USE GROUP: ='si bas°t 77/b.A-06- CFA)i:1,-72. ( 111.16z.. ....4.e-) L Pn,&t4l/'? t /.S>�'�- INSPECTION FEE $150.00 Please complete and return this application to the Department of Building Inspections, 212 Main Street, Northampton, MA 01060. We will contact you to arrange a time to inspect your property. If this information is not correct, or if you no longer own this property, please note any changes at the bottom or on the back of this form and return it to the building department. Feel free to contact us if you have any questions. We can be reached at (413) 587-1240. Thank you. 1 Applicant name: t'14.747 76. ---:--- . . . .*lit , . - . -... .. . .........,... . . .. ( 'IA g I/40 &AA ik-g4 .C .-/z)/ /g. .046- Applicant Title: i iitiot,j.k,r.: it,/ Telephone tS l ,.. . , . . u „ .... Preferred inspection time/date 7 i Comments: Basic Periodic Inspection Checklist Structural Items All structural and associated components(foundation,roof,walls, support members,stairs,sidewalks,etc.)are maintained in a safe and sound condition. Buildings are maintained in compliance with the Massachusetts Board of Fire Prevention Regulations and the Massachusetts State Building Code. . Required occupancy separations are provided'and maintained. Examples are dwelling unit/corridor,unit/unit, commercial/commercial or residential/commercial separations. � The Commonwealth of Massachusetts cy,5- • ;t City of Northampton New and Renewal Certificate of Inspection ��� In accordance to 780 CMR Chapter 1(The Ninth Edition of the Building Code)and Chapter 110 and the Acts of 2004,to further enhance fire and life safety,this certificate of inspection is issued to the premise or structure or part there as herein identified. Issued to Identify Name of Establishment: Certificate No. GANDARA CENTER 0033 Located at Identify property address including street number,name city or town and county Certificate Expiration 25 GRAVES AVE, Northampton 09/06/2024 32A-088-001 Use Group Classifications Allowable Occupant Load R-3 GROUP HOME 16 RESIDENTS / 6 STAFF This certificate of inspection is hereby issued by the undersigned to certify that the premise,structure or portion thereof as herein specified has been inspected for general fire and life safety features.This certificate shall be framed behind clear glass and/or laminated and posted in a conspicuous place within the space as directed by the undersigned.Failure to post or tampering with the contents of the certificate is strictly prohibited. Name of Municipal Name of Municipal Fire Chief CHIEF ANDY PEUS Building Inspector JONATHAN S. FLAGG Date of Inspection 09/06/2023 Signature of Signature of Municipal ;��� ��: Municipal Fire Chief Building Inspector ' Q. Date of Issuance 09/06/2023 Annual Emergency Lighting Test 25 Graves Street Northampton, MA Date: 5/9/2024 Type Location Number Battery Type Time Down_Time Up Battery Voltage Test Result Combo 1st Floor Front Entry 1 3.6V 9:32 AM 11:02 AM 3.2V PASS Emergency Light 1st Floor Front Entry 2 3.6V 9:33 AM 11:03 AM 3.4V PASS Emergency Light 1st Floor Front Hall 3 _ 6.0V 9:34 AM - - + Combo 1st Floor Rear Entry 4 3.6V 9:35 AM 11:05 AM 3.4V PASS Emergency Light 1st Floor Hall 5 6V 9:37 AM 11:07 AM 5.7V PASS Exit Sign _ 1st Floor Hall 6 1.2V 9:38 AM 11:08 AM 1.0V PASS Emergency Light 2nd Floor Hall 7 3.6V 9:40 AM 11:10 AM 3.3V PASS Exit Sign 2nd Floor Hall 8 1.2V 9:42 AM 11:12 AM 1.1V PASS Emergency Light 2nd Floor Hall 9 - 6V _ 9:44 AM 11:14 AM 5.6V PASS Emergency Light Stairs/2nd Floor 10 3.6V 9:46 AM 11:16 AM_ 3.5V PASS Combo 2nd Floor Rear Hall 11 3.6V 9:47 AM 11:17 AM 3.3V PASS Emergency Light 2nd Floor Porch 12 3.6V 9:48 AM 11:18 AM 3.2V PASS Emergency Light 2nd Floor Hall 13 3.6V 9:50 AM 11:20 AM 3.4V PASS Exit Sign 2nd Floor Hall 14 1,2V 9:53 AM 11:23 AM 1.0V PASS Emergency Light 2nd Floor Hall 15 3.6V 9:54 AM 11:24 AM 3.4V PASS Emergency Light Stairs 16 3.6V 9:56 AM 11:26 AM 3.2V PASS Emergency Light Basement 17 6.0V 9:58 AM 11:28 AM 5.4V PASS Emergency Light Basement 18 3.6V 10:00 AM 11:30 AM 3.2V PASS Exit Sign _ Basement 19 1.2V 10:03 AM 11:33 AM 1.0V PASS Emergency Light Basement 20 3.6V 10:05 AM - - + Combo Basement 21 3.6V 10:07 AM 11:37 AM 3.3V PASS •- Test or : JRS2 Electric, Inc. + Fixture Replaced and Tested on 5/9/24 * Battery Replaced and Tested on 5/9/24 Electric, Inc. MA License Number: 21377A Date: 5/9/24 • 1 of 1 , Report of Inspection / Test Annual NFPA 25 2024-06-11 Conducted by:Thomas Fournier Property Gandara Northampton Impact Fire Services 1032815662220289 533 Center Street PO Box 582 Building#: 1032815664497665 Ludlow MA 01056 25 Graves St ' 413-589-0672 Northampton MA 01060 Inspection Ref#:34882596 Report of Inspection / Test for System - Wet Fire Department Connection Is the FDC plainly visible? Yes Is the FDC easily accessible? Yes Is the FDC identification sign(s)in place? Yes Are the FDC swivels and couplings not damaged? Yes Are the FDC caps and plugs in place and undamaged? Yes Has the interior of the FDC been inspected for Yes obstructions? Are the FDC gaskets in place? Yes Is the FDC check valve free of leaks? Yes Is the visible piping supplying the FDC undamaged? Yes Is the clapper and automatic drain valve in place and Yes properly operating? Sprinkler Heads Are there proper number and type of spare sprinklers Yes Are there spare sprinkler head(s)and applicable Yes with a list in place? wrench(es)for all types,makes and model sprinklers installed In the system? Are all the sprinklers dated 1920 or later? Yes Standard response sprinklers 50 or more years replaced N/A or successfully sample tested within last 10 years? Date that standard response sprinklers 50 or more years N/A Standard response sprinklers 75 or more years old N/A were last tested: replaced or successfully sample tested within last 5 years? Date that standard response sprinklers 75 or more years N/A Fast response sprinklers 20 or more years old replaced N/A were last tested: or successfully sample tested within last 10 years? Date that fast response sprinklers were tested or N/A Dry-type sprinklers replaced or successfully sample N/A replaced: tested within last 10 years? Date that dry-type sprinklers were last tested: N/A Have sprinklers subject to harsh environments OR 325 N/A degrees or higher been replaced or successfully sample tested in the last 5 years? Date that sprinklers subject to harsh environments were N/A If a sprinkler failed a sample test were all the sprinklers N/A last tested: represented by that sample replaced Are visible sprinklers free of foreign materials including Yes Are visible sprinklers in the proper position:upright, Yes foreign paint? pendent,sidewall? Is there proper clearance below the sprinklers? Yes Is there liquid in all visible glass bulb sprinklers? Yes Sprinklers and spray nozzles protecting commercial N/A cooking equipment and ventilating systems replaced except for bulb-type which show no signs of grease buildup? Pipes Does visible pipe have no external loads? Yes Are the visible pipe and fittings in good condition with Yes no external corrosion? Do visible pipe and fittings have no mechanical damage Yes Are visible pipe hangers,supports,and seismic braces Yes or leaks? not damaged or loose? Copyright 2024 Inspect Point Page 2 of 7 Report of Inspection / Test Annual NFPA 25 2024-06-11 Conducted by:Thomas Fournier Property Gandara Northampton Impact Fire Services 1032815662220289 533 Center Street PO Box 582 Building#: 1032815664497665 Ludlow MA 01056 25 Graves St 413-589-0672 Northampton MA 01060 Inspection Ref#:34882596 Is the pipe through freezers free if any ice blockage? N/A Control Valve(s) Are the control valves with electrical supervision/locks Yes Are the control valves with electrical supervision/locks Yes accessible? properly identified? Are the control valves with electrical supervision/locks,is Yes Are the control valves with electrical supervision/locks in Yes the supervision in place? correct(open or closed)position? All control valves operated through full range and Yes Have post indicating valves been opened until spring or N/A returned to normal position? torsion felt in the rod and then closed back 1/4 turn? Do the control valves(PIV)with electrical N/A supervision/locks have the appropriate wrenches? Riser Area Is the information sign in place and legible indicating any Yes Is the sprinkler room maintained at a minimum of 40 Yes antifreeze,dry systems,pre-action systems,auxiliary degrees F? system controls valves,floor control and sectional valves,heat tape,and low point drains? Is the hydraulic name plate(calculated systems)or pipe Yes Are the gauges on system showing normal water supply Yes schedule sign attached securely to the riser and legible? pressure? Are the gauges on system operable and in good working Yes Date of gauges: 2023 condition? Is the trim/valves in correct(open or closed)position? Yes Is there no leakage in the retarding chamber or drains? Yes Are alarms and supervisory devices not damaged? Yes Is the riser valve free from physical damage? Yes Are Pressure reducing valves(sprinkler system)in open N/A Are Pressure reducing valves in good condition including N/A position and not leaking? no handwheels broken? Are Pressure reducing valves(sprinkler system)with N/A Have pressure reducing valves passed partial flow test? N/A downstream pressure per the design? Backflow Preverters Backflow Preventer Make: Ames Backflow Preventer Size: 2 Backflow Preventer Model: 200bdc Have backflow devices passed forward flow test? N/A Is the relief port on RPZ device not discharging N/A The reduced pressure backflow preventer(indicate size, N/A make,and model)is missing the air gap drain cup and piping to a safe discharge.Is there an air gap in place and proper drain? Maintenance Has an internal investigation of the pipe been N/A Date that the last internal pipe investigation was N/A performed in the last 5 years?(If no,conduct performed: investigation) Are there conditions found that warrant flushing of the N/A Was flushing of the system conducted? N/A system? Copyright 2024 Inspect Point Page 3 of 7 Report of Inspection / Test Annual NFPA 25 2024-06-11 Conducted by:Thomas Fournier Property Gandara Northampton Impact Fire Services 1032815662220289 533 Center Street PO Box 582 Building#: 1032815664497665 Ludlow MA 01056 25 Graves St 413-589-0672 Northampton MA 01060 Inspection Ref#:34882596 What date was the flushing conducted? N/A Has the the piping from the fire department connection N/A to the fire department check valve been hydrostatically tested at 150 psi(10 bar)for 2 hours at least once in the last 5 years? Date the piping from the fire department connection to N/A If sprinklers have been replaced,were they proper Yes the fire department check valve has been hydrostatically replacements? tested? Have backflow preventers been internally inspected to N/A If so,what date was backflow internally inspected? N/A verify all components are in good condition,operate correctly and move freely at least once in the last 5 years? Operating stem of all OS&Y valves lubricated,completely Yes Was a drain test conducted after opening any closed Yes closed and reopened? valve? Date the drain test was conducted: N/A Have adjusted,repaired,reconditioned,or replaced Yes components had proper tests/inspections performed? Was heat tape inspected per the manufacturer's N/A Are the pressure relief valves of wet systems that are N/A instructions? looped or gridded,in good condition and properly piped to drain safely? Were marine systems normally having fresh water N/A drained and refilled twice if raw water got into the system? Alarms and Supervisorys Have the mechanical waterflow alarm devices passed Yes The electrical waterflow alarm devices/pressure switches Yes tests by opening inspector's test connection/bypass passed test by opening inspector's test connection with alarms actuating and flow observed for connection/bypass connection with alarms actuating 5 minutes? and flow observed? Do valve supervisory switches indicate movement? Yes MAIN DRAIN FLOW TESTS System Initial Static Residual Static Seconds to Flow Did waterflow Are results Return to Observed? alarm operate? comparable Initial Static to previous test? Wet 115 105 115 3 Yes Yes Yes Copyright 2024 Inspect Point Page 4 of 7 Report of Inspection / Test Annual NFPA 25 2024-06-11 Conducted by:Thomas Fournier Property Gandara Northampton Impact Fire Services 1032815662220289 533 Center Street PO Box 582 Building#: 1032815664497665 Ludlow MA 01056 25 Graves St 413-589-0672 Northampton MA 01060 Inspection Ref#:34882596 Questions with Photos and Notes Wet-Has the the piping from the fire department connection to the fire department check valve been hydrostatically tested at 150 N/A psi(10 bar)for 2 hours at least once in the last 5 years? Notes: System installed in 2023 Wet-Fast response sprinklers 20 or more years old replaced or successfully sample tested within last 10 years? N/A Notes: System installed in 2023 Copyright 2024 Inspect Point Page 5 of 7 Report of Inspection / Test Annual NFPA 25 2024-06-11 Conducted by:Thomas Fournier Property Gandara Northampton Impact Fire Services 1032815662220289 533 Center Street PO Box 582 Building#: 1032815664497665 Ludlow MA 01056 25 Graves St 413-589-0672 Northampton MA 01060 Inspection Ref#:34882596 Deficiencies- General Questions None IDeficiencies-General Wet System Questions I None IDeficiencies-Wet None Copyright 2024 Inspect Point Page 6 of 7 Report of Inspection / Test Annual NFPA 25 . 2024-06-11 Conducted by:Thomas Fournier Property Gandara Northampton Impact Fire Services 1032815662220289 533 Center Street PO Box 582 Building#: 1032815664497665 Ludlow MA 01056 25 Graves St 413-589-0672 Northampton MA 01060 Inspection Ref#:34882596 Inspector Signature I state that the information on this form is correct at the time and place of my inspection,and all equipment tested at this time was left in operational condition upon completion of this inspection except as noted. Inspector Name Signature Date Completed Thomas Fournier 2024-06-11 Copyright 2024 Inspect Point D,,rtn 7 of 7 SYSTEM RECORD OF INSPECTION AND TESTING This form is to be completed by the system inspection and testing contractor at the time of a system test. 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 calcul/a ioonnszias necessary to provide a complete reco Inspection/fest Start Date/Time: 6:3.,9 I,at V /)� lrispectionlfest Completion Date/Time: t34?D�L'i ,.; z`-y., Supplemental Form(s)Attached: (yes/no) V 1. PROPERTY INFORMATION Name of property: Gandara Mental Health(Harriston House) Address: 25 Graves Ave Description of property: Name of property representative: Address: Phone: Fax: E-mail: 2. TESTING AND MONITORING INFORMATION Testing organization: Eastern Electronics&Security,Inc. Address: 540 Main Street West Springfield,MA 01089 Phone: 413-736-5181 Fax: 413-736-0129 E-mail: wporfilio©ees-security.com Monitoring organization: Cetra-Larm Monitoring Address: 994 Candia Road Phone: 800-639-2066 Fax: E-mail: Account number: SLIP7831 Phone line 1: Phone line 2: Means of transmission: Cell radio Entity to which alarms are retransmitted: Phone: 3. DOCUMENTATION On-site location of the required record documents and site-specific software: 4. DESCRIPTION OF SYSTEM OR SERVICE 4.1 Control Unit Manufacturer: Edwards Model number: E-FSC-1004 4.2 Software and Firmware Firmware revision number: 4.3 System Power 4.3.1 Primary(Main)Power / ^ Nominal voltage: 120vac ,,nn Amps: 20 amps Location: /J„r`e(1i/v,.vb/ Overcurrent protection type: I3�c`1(Zt\,iAmps: E/, ?5/ Disconnecting means location: ErcA '�f( Copyright®2012 National Fire Protection Association.This form may be copied for individual use other than for resale.II may not be copied for commercial sale or distribution. (p. 1 of 4) SYSTEM RECORD OF INSPECTION AND TESTING(continued) 4. DESCRIPTION OF SYSTEM OR SERVICE(continued) 4.3.2 Secondary Power Type: Batteries Location: Control Panel Battery type(if applicable): Sealed Lead Calculated capacity of batteries to drive the system: In standby mode(hours): In alarm mode(minutes): 5. NOTIFICATIONS MADE PRIOR TO TESTING Monitoring organization Contact: (i"'1/L[.. /\IRCin Time: 1 I ', 1 D Building management Contact: jt-f Fr: Time: Vir 1, 't; Building occupants Contact: A 1 l Time: !/ .is Authority having jurisdiction Contact: Time: Other,if required Contact: Time: 6. TESTING RESULTS 6.1 Control toil and Related Equipment Visual Functional Description Inspectio Test Comments Control unit ^� Lamps/LEDs/LCDs lJ / Zr �y Fuses t—_1/ L1/ Trouble signals 12 Cr Disconnect switches 0"- Ground-fault monitoring if l! Supervision 2( L7d Local annunciator Remote annunciators I Er Remote power panels 0 0 a L I ❑ (/ 6.2 Secondary Power Visual Functional Description Inspection Test Comments Battery condition UV Load voltage UV ibi i Discharge test l Charger test Vit Remote panel batteries 0 0 z' ' IN Copyright 02012 National Fire Protectan Association.This form may be copied for irtjividual use other than for resale It may not be coped for commercial sale or astir out on 2 `4 SYSTEM RECORD OF INSPECTION AND TESTING(continued) 6. TESTING RESULTS(continued) 6.3 Alarm and Supervisory Alarm Initiating Device Attach supplementary device test sheets for all initiating devices. 6.4 Notification Appliances Attach supplementary appliance test sheets for all notification appliances. 6.5 Interface Equipment Attach supplementary interface component test sheets for all interface components. Circuit Interface/Signaling Line Circuit Interface/Fire Alarm Control Interface 6.6 Supervising Station Monitoring Description Yes No Time Comments Alarm signal H ❑ Alarm restoration 0 Trouble signal O ❑ Trouble restoration ❑ Supervisory signal ❑ Supervisory restoration pr ❑ 6.7 Public Emergency Alarm Reporting System Description Yes No Time Comments Alarm signal ❑ ❑ y l� Alarm restoration 0 ❑ Trouble signal ❑ ❑ ( �,/� Trouble restoration ❑ ❑ N I Supervisory signal ❑ 0 Supervisory restoration 0 ❑ /I/ �J Copyright 02012 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 4) SYSTEM RECORD OF INSPECTION AND TESTING(continued) 7. NOTIFICATIONS THAT TESTING IS COMPLETE 22�� Monitoring organization Contact: G"ra_1_, Af e(c Time: Building management Contact: 6 j v a- Time: 62_ Building occupants Contact: a\` Time: -3 0 Authority having jurisdiction Contact: Time: Other,if required Contact: Time: 8. SYSTEM RESTORED TO NORMAL OPERATION Date: (a' Time: - 9. CERTIFICATION This system as specified herein has been i • ed lald teste�+3eearditt to NFPA 72,2013 edition,Chapter 14. Si a Printed name —1`-/c ' Date: (p `3 ', a / anization: EEIn . Title: Technician Phone: Qualifications(refer to 10.5.3): 10. DEFECTS OR MALFUNCTIONS NOT CORRECTED AT CONCLUSION OF SYSTEM INSPECTION, TESTING,OR MAINTENANCE 10.1 Acceptance by Owner or Owner's Representative: The undersigned accepted the test report for the system as specified herein: Signed: Printed name: Date: Organization: Title: Phone: Copyright 0 2012 National Fire Protect on Association.This form may be copied for individual use other than for resale It may not be copied for commercial sale or distribution. (p.4 of 4) • as Eczs tY'YL 640 Main Street s i 7 Electronics 4& West Springfield, MA 01089 '' r .` � , ''.` 1'12C (413) 736-6181 Fax: (413) 736-0129 FIRE ALARM TEST & INSPECTION FORM Zone Trouble ignal ALPower Trouble Conditions: ormal ❑ Note# mal ❑ Note# Normallr/ ormal ❑ Note# Central Monitoring Normal El Note# Line# 1 ( ) /y Station C t 1k f 1- (1-t A • , , L 'JuMMV try LI0-Qh- Line#2( ) City Connection ❑ Normal n Note# Number dicating Zones # 5 City Box# N ❑ Note# Number of Initiating Inand ❑ Graphic 0 Lamp Test❑ Remote Test Zones # 10 Annunciator 4011. AUX Type Functions Battery Voltage V91terge with Note# Drop 0 Drill SW Remote ACK Under Load harge Door Holders D Note# Normal. Elevator ❑ N/A ❑Normal ❑ Note# Fire Recall N/A Failure from NFPA Standards: None ❑Corrective Action / ` / Te ici\\ anSjgnat ate Customer Signature Date PSD= otoelectric Smk Det CPS=Coded Pull Station B=Bell Only TS=Tamper Switch ISD=Ionization Smk Det RR=Rate of Rise Heat Det H=Hom Only WF=Water Flow PDD=Photo Duct Smk Det HT=Fixed Temp Heat Det C=Chime Only DH=Door Holder IDD=Ion Duct Smk Det MD=Mercoid Heat Det S=Sprinkler Only FP=Fire Phone DHS=Door Hldr&Smk Det FD=Flame Det AN=Audio Visual PJ=Phone Jack SSD=Sgl Station Smk Det PS=Manual Pull Station V=Visual Only NCS=Nurse Call Station BD=Beam Det P=Passed F=Failed FIRE ALARM TEST & INSPECTION FORM Device Device Location Alarm ispop 4.,tioo° Note* Device Device Location Alarm 4tiVc2 4 Ace Note# Type Type PS L. ENTRY P 2 PSD 2ND FL. L FRONT HALL 3 PS R. ENTRY 2 PSD BEDROOM#8 3 PSD L. ENTRY 2 PSD BEDROOM#7 3 PSD R. ENTRY r" 2 PSD BEDROOM#6 3 AV R. ENTRY P PSD BEDROOM#5 v 3 Y AN FRONT PORCH i PSD 2ND FL. L BACK HALL ;) ' 3 HT LIVING ROOM f 2 HT/RR 2ND FL. L BATHROOM 3 p HT/RR KITCHEN f 2 V 2ND FL. L BATHROOM PS KITCHEN DOOR Q 2 PSD 2ND FL. R. BACK HALL 3 AV KITCHEN PS 2ND FL BACK HALL 3 PS BACK DOOR 2 AV 2ND FL BACK HALL ..ej PSD BACK DOOR ,P 2 HT/RR 2ND FL R BATHROOM 3 PSD BACK OFFICE P 2 V 2ND FL R BATHROOM r PSD FRONT OFFICE 1 2 PSD BEDROOM#4 Pri 3 V HANDICAP BATHROOM 1 PSD 2ND FL R STAIRWAYr 3 PSD BEDROOM#1 9 2 PSD 2ND FL R FRONT HALL P 3 V BEDROOM#1 PSD BEDROOM#3 3 PS 2ND FL L. STAIRWAY 3 PSD BEDROOM#2 3 AV 2ND FL L. STAIRWAY PS 2ND FL R TOP OF STAIRS 3 Failure from NFPA Standards: None Corrective Action C----- 6 3 goy ecnician Signature Date Customer Signature Date PSD=Photoelectric Smk Det CPS=Coded Pull Station B=Bell Only TS=Tamper Switch ISD=Ionization Smk Det RR=Rate of Rise Heat Det H=Horn Only WF=Water Flow PDD=Photo Duct Smk Det HT=Fixed Temp Heat Det C=Chime Only DH=Door Holder IDD=Ion Duct Smk Det MD=Mercoid Heat Del S=Sprinkler Only FP=Fire Phone DHS=Door Hldr&Smk Det FD=Flame Det NV=Audio Visual PJ=Phone Jack SSD=Sgl Station Smk Det PS=Manual Pull Station V=Visual Only NCS=Nurse Call Station BD=Beam Det P=Passed F=Failed C/0=CARBON MONOXIDE FIRE ALARM TEST & INSPECTION FORM Device Device Location Alarm ,�v� o° Note# Device Device Location Alarm ,$/c G71 o° Note# Type 5Q ti° Type �� ti° HT ATTIC (L) - HRR 4 CO L. CELLAR 5 HT ATTIC (R) - HRR 4 CO R. CELLAR P 5 PSD L. CELLAR STAIR ! 1 CO 1ST FL. BY RM#1r 5 HT L. CELLAR FRONT l 1 CO 2ND FL. BY RM#6 5 HT L. CELLAR BACK 1 CO 2ND FL. BY RM#5 5 AV L. CELLAR 1 CO 2ND FL. BY RM#3 5 PSD R. CELLAR 1 CO 2ND FL. BY RM#4 5 HT/RR R. CELLAR FRONT 1 H 2ND FL. R. HALL HT R. CELLAR BACK 1 H 2ND FL. L. HALL P PS R. CELLAR BACK 1 H 1ST FL. R. FR HALL Al f PS L. CELLAR BACK 1 HTRR KITCHEN BATHROOM F. 1 V KITCHEN BATHROOM ) 1 AN ANSUL SYSTEM IQ 6 Failure from NFPA Standards: None Corrective Action ,-__ -3 6 '- '6.3 ‘),Ot Tecnician Signature Date Customer Signature Date PSD=Photoelectric Smk Det CPS=Coded Pull Station B=Bell Only TS=Tamper Switch ISD=Ionization Smk Del RR=Rate of Rise Heat Det H=Horn Only WF=Water Flow PDD=Photo Duct Smk Det HT=Fixed Temp Heat Det C=Chime Only DH=Door Holder IDD=Ion Duct Smk Det MD=Mercoid Heat Det S=Sprinkler Only FP=Fire Phone DHS=Door Hldr&Smk Det FD=Flame Det AN=Audio Visual PJ=Phone Jack SSD=Sgl Station Smk Del PS=Manual Pull Station V=Visual Only NCS=Nurse Call Station BD=Beam Det P=Passed F=Failed CO=Carbon Monoxide