Stanley_Chapel-FA-6-11-12.pdf

Inspection Date JUNE 11,2012

Company Name SimplexGrinnell

Address Address

City State & Zip City, State & Zip

Owner Contact

Building

Transmission Type

Last Service Date

December 14th 2007

Quantity Circuit Style

21 B

10 B

High Pressure Switch

Alarm Verification feature is

Ionazation Smoke Detector

Comments

Photoelectric Smoke Detector

Software Revision

Annual Inspection Simplex 4002

Service Type

Waterflow Switch

ALARM INITIATING DEVICES AND CIRCUIT INFORMATION

Building Occupants AHJ Notified of pre-existing Impairments

# Of CircuitsInitiating Circuit Style # Of Circuits Notification Circuit Style

NOTIFICATIONS MADE PRIOR TO ANY TESTING

DATE & TIME

Secuirty Office

7:00AM

WILLIE SAMPSON/JEFF SPICKNALL

22712 COMMERCE CTR CT #114

DULLES, VA 20166

Office Phone

Office License # 564

TROY

Central Station Operator January 15th 2009 12:45pm

Stanely Chapel

703-996-0782

Monitoring Entity

Central Station Phone Number

Monitoring System Account Number

Secuirty Office

See Sprinkler Report

NAMEENTITY NOTIFIED

Building Management

Duct Detector

Heat Detector

Device Type

Fire Pump Run

See Sprinkler Report

Multi-Sensor

Armed Forces Retirement Home

Kitchen Hood System

Optical Detector

Manual Pull Station

Beam Detector

Telephone Date of Last Software

Revision Manufacturer MODEL

FIRE ALARM SYSTEM

NFPA 72 REPORT OF INSPECTION and TEST (Page 1 of 4)

202-730-3111

Inspection Time

3700 North Capitol St. NW

Inspection Report Number

Washington, DC 20011

Inspection Contract Number

Approving Agency

Contact

WILLIE SAMPSON 129164

Chemical Fire Suppression System

Inspection Technician SignatureLicense Number

Owner: Jack Kleminich Author: Eugene Turek Last Revised: 11/13/2003

Company Name

Quantity Circuit Style

4 B

9 B

Quantity Circuit Style

Quantity

120 VAC 20

BREAKER 20

VISUAL

YES

N/A

YES

YES

YES

YES

YES

YES

N/A

YES

VISUAL

YES

Specific Gravity N/A

Transient Suppressors

Charger Test YES Discharge Test YES

SYSTEM TESTS AND INSPECTIONS SECONDARY POWER

Trouble Signals Disconnect Switches

Remote Annunciators

PRIMARY SYSTEM POWER SUPPLIES SECONDARY (STANDBY) POWER SUPPLY

Fire Pump Loss of Phase

Generator Run Indicator

Bell

AND STYLE OF SIGNALING LINE CIRCUITS CONNECTED TO THIS SYSTEM

Water Tank Level

PIV Tamper

Horn

Speaker

Chime

ALARM NOTIFICATION APPLIANCES AND CIRCUIT INFORMATION

Are circuits monitored for electrical integrity?

Device Type

YES

Comments

Horn / Strobe

Speaker / Strobe

Chime / Strobe

If the answer is "YES" what type & article as defined in NFPA 70

Fire Pump Trouble

Over current Protection Type Amps Calculated capacity to operate the system, in hours

Amps Battery Type 12 Volt

Location of Supply Panel board Basement Type of engine-driven generator dedicated to alarm system

Is an Emergency or Standby system used as a backup to primary power supply, instead of using a secondary power supply

Amp Hr RatingPrimary Main Nominal Voltage

Low Pressure Switch

Fuses YESPrimary Power Supply

Battery Condition

Ground - Fault Monitoring N/A

FUNCTIONALTYPE

Inspection Date JUNE, 11,2012

Main Panel (1) 13.23 volts 5.61 AH (2) 13.34 volts 4.67 AH

Location of Fuel Storage

FIRE ALARM SYSTEM

NFPA 72 REPORT OF INSPECTION and TEST (Page 2 of 4)

Armed Forces Retirement Home

Load Voltage YES

YES

YES

Disconnecting means location

Inspection Report Number Inspection Contract Number

SUPERVISORY SIGNAL INITIATING DEVICES AND CIRCUIT INFORMATION

Device Type Comments, Incidents, or Deficiency Notes

OS & Y Tamper See Sprinkler Report

Plug Tamper

SYSTEM TESTS AND INSPECTIONS CONTROL PANELS

TYPE FUNCTIONAL COMMENTS

Control Unit Interface Equipment Lamps & LED's

Strobe

COMMENTS

YES

YES

N/A

YES

YES

VISUAL

YES

YES

N/A

VISUAL

N/A N/A N/A N/A N/A N/A

VISUAL

N/A N/A N/A N/A N/A N/A N/A N/A N/A

VISUAL

N/A N/A N/A N/A N/A N/A

RESULT

YES

YES

YES

YES

# YES

N/A

Kitchen Hood System

TYPE TIME COMMENTS

Alarm Signal

Pre-Action System N/A

CENTRAL STATION SIGNAL VERIFICATION

AFFF Foam System

Dry Chemical System N/A Deluge System N/A

N/A Alarm Restoration

TYPE FUNCTIONAL COMMENTS

SYSTEM TESTS AND INSPECTIONS SPECIAL HAZARD SYSTEMS

N/A

Supervisory Signal N/A

Fire Damper Control N/A

Gas Suppression System N/A

Emergency Power Shunt Trip N/A

Tone Generator (s) N/A

Did not perform annual elevator inspection.

Elevator Shunt Trip

Exhaust Fan Shut Down

Amplifier (s) N/A

Off - Hook Indicator N/A

TYPE FUNCTIONAL COMMENTS

Voice Clarity N/A

SYSTEM TESTS AND INSPECTIONS EMERGENCY COMMUNICATIONS EQUIPMENT

N/APhone Set

TYPE FUNCTIONAL

Speakers N/A

YES

Visible YES

SYSTEM TESTS AND INSPECTIONS NOTIFICATION APPLIANCES

TYPE FUNCTIONAL COMMENTS

Audible

Inspection Date Jun-12

FIRE ALARM SYSTEM

NFPA 72 REPORT OF INSPECTION and TEST (Page 3 of 4)

Armed Forces Retirement Home

Inspection Report Number Inspection Contract Number

SYSTEM TESTS AND INSPECTIONS INTERFACE EQUIPMENT

Elevator Recall

Door Release to Close N/A Door Unlock N/A

N/A

Supervisory Restoration N/A

Smoke Control System N/A HVAC Shut Down N/A

N/A

Trouble Signals N/A N/A

N/A

COMMENTS

N/ACall - in Signal

Phone Jacks N/A

Date

System Restored to Normal Operation? NO Date Time

Building Occupants

Central Station Operator Secuirty Office

Building Management

Supervising Technician License Number

NOTIFICATIONS THAT TESTING IS COMPLETE

ENTITY NOTIFIED

FIRE ALARM SYSTEM

NFPA 72 REPORT OF INSPECTION and TEST (Page 4 of 4)

Armed Forces Retirement Home

NAME DATE & TIME

Inspection Date JUNE 11,2012

Inspection Report Number Inspection Contract Number

This Fire Alarm System was left with the Annuciator Trouble.

THIS IS TO CERTIFY THAT THE FIRE ALARM SYSTEM HAS BEEN TESTED AND INSPECTED IN ACCORDANCE WITH THE APPLICABLE NFPA STANDARDS

SYSTEM WIDE INCIDENT, COMMENTS, AND DEFICIENCY SECTION

FIRE ALARM SYSTEM DEVICE RECORD

Armed Forces Retirement Home

Inspection Report Number

Location Are a or Fl oo r

Dev ice

De sc rip tio n Ta sk Fr eq ue nc y

Dev ice

Ad dr es s or

Circ ui t N um be r

Ala rm

O pe ra tio n Ve rif ie d

Ann un ci at or In di ca tio n

Rem ot e In di ca tio n

La m p

Su pe rv is io n of Dev ic e

Dev ic e Cle an ed th is in sp ec tio n

Se ns iti vi ty Se tti ng

(0

4) or

Fl ow

Sw itc h De la y

Ti m er

Comments

At Chapel Entrance (1) 1st Floor Smoke Detector Annual

At Chapel Entrance (2) 1st Floor Smoke Detector Annual Chapel (1) 1st Floor Pull Station Annual X X X P Chapel (2) 1st Floor Pull Station Annual X X X P Chapel (3) 1st Floor Pull Station Annual X X X P Chapel Exit (1) 1st Floor Pull Station Annual X X X P Chapel Exit (2) 1st Floor Pull Station Annual X X X P Chaplain's Office 1st Floor Smoke Detector Annual X X X X X P Elevator Lobby 1st Floor Smoke Detector Annual X X X X X P Main Entrance 1st Floor Pull Station Annual X X X P Balcony (1) 2nd Floor Smoke Detector Annual X X X X X Balcony (2) 2nd Floor Smoke Detector Annual X X X X X Top of Stairs 2nd Floor Pull Station Annual X X X P Corridor Kitchen (Bottom of Ramp) Basement Smoke Detector Annual X X X X X P Mechanical Room Basement Smoke Detector Annual X X X X X P Electrical Room Basement Smoke Detector Annual X X X X X P

NO Access NO Access

Company Name:

Inspection Report Number:

Date:

Page:

Location Are a or Fl oo r

Dev ice

De sc rip tio n Ta sk Fr eq ue nc y

Dev ice

Ad dr es s or

Circ ui t N um be r

Ala rm

O pe ra tio n Ve rif ie d

Ann un ci at or In di ca tio n

Rem ot e In di ca tio n

La m p

Su pe rv is io n of Dev ic e

Dev ic e Cle an ed th is in sp ec tio n

Se ns iti vi ty Se tti ng

(0

4) or

Fl ow

Sw itc h De la y

Ti m er

Comments

Company Name:

Inspection Report Number:

Date:

Page:

Elevator Lobby Basement Smoke Detector Annual X X X X X P Exit by Elevator Basement Pull Station Annual X X X P Hallway by Rooms Basement Pull Station Annual X X X P Kitchen Basement Smoke Detector Annual X X X X X Men's Room Basement Smoke Detector Annual X X X X X Room 1 Basement Smoke Detector Annual X X X X X P Room 3 Basement Smoke Detector Annual X X X X X Room 4 Basement Smoke Detector Annual X X X X X Room 5 Basement Smoke Detector Annual X X X X X Conference Room Basement Smoke Detector Annual P Conference Room Basement Smoke Detector Annual P Conference Room Basement Pull Station Annual P Room 6 Basement Smoke Detector Annual X X X X X Side Exit (Top of Ramp) Basement Smoke Detector Annual X X X X X P Side Exit (Top of Ramp) Basement Pull Station Annual X X X P Corridor By Room 100 Basement Smoke Detector Annual X X X X X P Conference Room Basement Pull Station Annual P Fellowship Hall 1st Floor Smoke Detector Annual X X X X X P Fellowship Hall 1st Floor Smoke Detector Annual X X X X X P Fellowship Hall 1st Floor Smoke Detector Annual

NO Access

NO Access

NO Access NO Access NO Access

NO Access or Fl oo r

Dev ice

De sc rip tio n Ta sk Fr eq ue nc y

Dev ice

Ad dr es s or

Circ ui t N um be r

Ala rm

O pe ra tio n Ve rif ie d

Ann un ci at or In di ca tio n

Rem ot e In di ca tio n

La m p

Su pe rv is io n of Dev ic e

Dev ic e Cle an ed th is in sp ec tio n

Se ns iti vi ty Se tti ng

(0

4) or

Fl ow

Sw itc h De la y

Ti m er

Comments

Company Name:

Inspection Report Number:

or Fl oo r

Dev ice

De sc rip tio n Ta sk Fr eq ue nc y

Dev ice

Ad dr es s or

Circ ui t N um be r

Ala rm

O pe ra tio n Ve rif ie d

Ann un ci at or In di ca tio n

Rem ot e In di ca tio n

La m p

Su pe rv is io n of Dev ic e

Dev ic e Cle an ed th is in sp ec tio n

Se ns iti vi ty Se tti ng

(0

4) or

Fl ow

Sw itc h De la y

Ti m er

Comments

Company Name:

Inspection Report Number:

or Fl oo r

Dev ice

De sc rip tio n Ta sk Fr eq ue nc y

Dev ice

Ad dr es s or

Circ ui t N um be r

Ala rm

O pe ra tio n Ve rif ie d

Ann un ci at or In di ca tio n

Rem ot e In di ca tio n

La m p

Su pe rv is io n of Dev ic e

Dev ic e Cle an ed th is in sp ec tio n

Se ns iti vi ty Se tti ng

(0

4) or

Fl ow

Sw itc h De la y

Ti m er

Comments

Company Name:

Inspection Report Number:

OTHER

SMOKE/FIRE DAMPERS

SMOKE HATCH

EXHAUST FAN

DOOR UNLOCK

SPEAKER

SPEAKER/STROBE

DOOR RELEASE

FAN SHUTDOWN

HORN

HORN/STROBE

VISUAL ONLY (STROBE)

CHIME

CHIME/STROBE

OTHER

OS & Y TAMPER SWITCH

LOW PRESSURE SWITCH

PLUG TYPE TAMPER

WATER LEVEL SWITCH

FIRE PUMP INDICATOR

ANNUNCIATOR

Comments

See Sprinkler Report

See Page 4

9 9 0 0

4 4 0 0

FIRE EXTINGUISHING OR SUPPRESSION SYS SWITCHES

FIRE/GAS & OTHER DETECTORS

FIRE PUMP RUNNING

21 15 0

10 10

SMOKE DETECTORS

HEAT DETECTORS

DUCT DETECTORS

BEAM DETECTORS

MANUAL PULL STATION

ELECTROMECHANICAL RELEASING DEVICE

DEVICE TYPE FIRE

ALARM SUPERVISORY DEVICES

SYSTEM TOTAL

NUMBER TESTED

THIS INSPECTION

NUMBER FAILED

THIS INSPECTION

NUMBER NOT

TESTED THIS

INSPECTION

Comments

FIRE ALARM DEVICE and TEST SUMMARY

Inspection Contract NumberInspection Report Number

Company Name: Armed Forces Retirement Home Inspection Date JUNE, 2012

NUMBER NOT

TESTED THIS

INSPECTION

CommentsDEVICE TYPE FIRE

ALARM INITIATING

SYSTEM TOTAL

NUMBER TESTED

THIS INSPECTION

NUMBER FAILED

THIS INSPECTION

CommentsNUMBER FAILED

THIS INSPECTION

NUMBER FAILED

THIS INSPECTION

NUMBER NOT

TESTED THIS

INSPECTION

NUMBER NOT

TESTED THIS

INSPECTION

DEVICE TYPE FIRE

ALARM NOTIFICATION

SYSTEM TOTAL

DEVICE TYPE FIRE

ALARM AUXILIARY CONTROL

SYSTEM TOTAL

NUMBER TESTED

THIS INSPECTION

1 1

NUMBER TESTED

THIS INSPECTION