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IFC 901.2.1 FPSC.pdf�r, ish Countmulti-jurisdictional Snohomish COMPLIANCENCE STATEMENT OF FIRE PROTECTION SYSTEM The purpose of this form is to ensure that projects are proAerrematWrty dely submitted may resufoning and ready for te+ntcancellanon f the inspection is scheduled. Compliance statements falsely or p inspection and an automatic re -inspection fee or other financial penalties by the local jurisdiction. INSTRUCTIONS: This compliance statement must be completed and submitted to the AHJ prior to scheduling acceptance testing. In accordance with 901.2.1 of the International Fire Code, I hereby affirm the following, indicated by my initials and signature: U TEMENTreprotection system noted below has been properly and completely lled in accordance with approved plans. oved plans will be immediately available for review on site at the time of inspection. i2LPermits have been paid for and will be immediately available for review on site at the time of inspection. The indicated fire protection system has been tested in accordance with the manufacturer's specifications and the appropriate installation standard. Deviations from the design standards (check one) -- No deviations from design standards: ❑ Deviations are as follows (attach approval of deviations): T e of S stem limit one er ertrFit number ; Fir_ e_ Other Fire Sprinkler 0 Household ❑ ❑ Standpipe ❑ Underground Commercial ❑ Hood Suppression ❑ NFPA 13-D ❑ Other NFPA 13-R �t✓�c�,�', �LCJb(��14 LJQ NFPA 13 el lC ►� �J�' rJ v�t`X�� PERMIT # y{�f;a,�G1� i`hmi6l�l`t 1NST,P LLAT,ION ADDRESS CITY l TALLING CONTRACTOR SIGNATURE PRINTED NA E AUTHORITY HAIAING LICENSE # JURISDICTION'. _ PLEASE FA}C THIS OQMPLETED STATEMENT TO THE PROPER Citv Marvsviile: 36f] $2 City of. Arlinaton: City of Brier: .36Q.403:9267 425.551.1261 of city of Miil,Creek: y Monroe: 425.745.9550 380 794:0959 Town of 17arriii.gtan: M0,435.0561 :425:7T5.772 l City of City of Mountlake Terrace:. 425 55 f,.12B1 513.2754 City of Edmonds: 'City'of Everett. "- �426.257.8139 - city of Mukiltea: y City of Snohomish: 425 36�.a5$.1375 City of Gold Bar City ofGran�te Falls: 360:793.8998 ,36a!391.6734 City of Stanwood: 38t}.629.6294 350 793;3344 Town of index: 425.388,387© City of Sultan: Town of Wo6dway:' 425 775'7721 ' C4ty of La1ce Steven 425.334.6981 425.711.7977 Snohomish County: ?425 388.3*j70 City, of :LynOwood: 1 FIRE- DISTRICT Fire Alarm Checklist Name of Building or complex ( [-, Derr _ Date 3_ I--- Address Permit numberj),j�,�J,, -'-H Fire alarm system complete andFire alarm system pre -testing complete [ ] Building occupants (if applicable) notified of fire alarm testing System is in test mode J4 SnoCom has been notified Tj Knox'Nox has been provided TJq [ ] Remote annunciator is properly located, accessible, not obstructed and conforms to approved plans f4 Fire alarm control panel is properly located, accessible, and not obstructed and conform to approved plans. CH,Approved signage-has been provided. This includes signage to specific locations and specific features. ( ie. Dry Standpipe and FDC) W Provide the alarm monitoring company's name and 24 hr number on the control panel. Monitoring company's name E�. a -)gig [ Provide a manual pull station reset key(s) as needed for the Knox box.�je,,, System loss of ac power, verify operation standby power �A [ ] AES check list completed (on reverse side) ", Fire alarm control panel circuit breaker shall be labeled FACP, painted red, and locked in the ON position. (A. Fire alarm panel shall indicate what circuit breaker supplies power and the location of the panel where that circuit is located. R on odevices (minimum o Check a random selection initiating f 25%)�> � Lam? �,-► 0kpz, V] Activation of audible, visual and audible / visual devices. Verify visual synchronization U], Outside horn / strobe activation and location Verify alarm, supervisory, and trouble retransmission signals to monitoring station �61 Require Certificate of completion from installer Signature of Fire Official-=.�, 12425 Meridian Avenue S / Everett WA 98208 / 425-551-1200 www.firedistrict1.org