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Kiran Vankudre
Kiran Vankudre

This document provides information about a fire alarm system for a protected property. It details the alarm service company and contact information, the type of fire alarm system installed according to NFPA standards, the components of the system including detectors, sprinklers, manual pull stations, and notification devices, and how alarms are transmitted remotely for monitoring. It also notes any deviations from NFPA standards or coverage requirements.

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SN: Underwriters Laboratories Inc. 速 333 Pfingsten Road, Northbrook, IL 60062-2096 Phone: (847) 664-2645, Fax: (847) 407-1001 Fire Alarm System Description Worksheet PROTECTED PROPERTY Name: ________________________________________________________________________ Address: ______________________________________________________________________ City: ____________________ State: ________ Zip Code: ___________________ Representative Name (please print): ________________________________ ALARM SERVICE COMPANY File No: _____________________ Service Center Number: __________________ Name: ________________________________________________________________________ Address: ______________________________________________________________________ City: ____________________ State: _________ Zip Code: _________ Representative: Phone Number: Name (please print): __________________ ( ) ____________________ Representative Fax Number: Title (please print): ____________________ ( ) ____________________ PERIOD OF ISSUANCE Note: Issue date must be within the last 30 days or request cant be processed. Certificates may be issued from 1 to 5 years. Issue Date: ___/___/___ Expiration Date: ___/____/___ Old Serial Number (If applicable): _________________ New ________ Renewal _________ Replacement __________ Copyright 2007 1 Revised 05/21/2007 UL Form No. CS-ASD-FAS
COMMENTS AND CLARIFICATIONS Note: Clarify location or area of coverage, as needed. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ AREA COVERED Note: Buildings, Floors or Area(s) should be listed here ______________________________________________________________________________ ______________________________________________________________________________ ALARM SYSTEM DESCRIPTION SYSTEM TYPE System Type: System is installed and maintained in compliance with Standard identified. Type NFPA Edition Year (Circle One) (Circle One) Central Station NFPA 71 or NFPA 72 __________ Local NFPA 72 or NFPA 72A __________ Auxiliary NFPA 72 or NFPA 72B __________ Remote Station NFPA 72 or NFPA 72C __________ Proprietary NFPA 72 or NFPA 72D __________ Authority Having Jurisdiction, i.e., Requiring Certification (List Below): ______________________________________________________________________________ Responding Fire Department (List Below): ______________________________________________________________________________ Date of Periodic Test Agreement: _____ / ______ / ______ (mm/ dd / year) * Please note a testing and maintenance contract date is required. Copyright 2007 2 Revised 05/21/2007 UL Form No. CS-ASD-FAS
AUTOMATIC FIRE DETECTION AND ALARM SERVICE Type Description (Circle One) Total Detectors are installed in all areas, rooms, and spaces as defined in Standard NFPA 72 or NFPA 72E (National Fire Alarm Code) Chapter 5. Selected Area Same code requirements as total coverage but protection is only provided for specifically defined area(s) of the protected property. In addition selected coverage may include smoke detection at control units. Must describe details in Comments and Clarifications Section. Partial Deviations from Total or Selected Area Coverage. Protection provided is less then required by the code in some way. Number of devices and locations shall be specified. Must describe details in System Deviations Section. Quantity Quantity Quantity Quantity Smoke Detectors _____ _____ Ion _____ Photo Duct Detectors _____ _____ Ion _____ Photo Heat Detectors _____ _____ ROR _____ Fixed Temp _____ Combination Other: _____ Details: ________________________________________________________ SPRINKLER SYSTEM WATERFLOW ALARM AND SUPERVISORY SERVICE Note: If all sprinkler risers and water shutoff valves are not supervised, show in deviations section. Type of System: _____Wet Pipe _____Dry Pipe Quantity _______ Waterflow Switches (Includes water pressure type) _______ Sprinkler Valve Supervisory Switches Other Supervisory Services: Quantity Quantity Quantity ____Water Pressure Devices ____Air Pressure Devices ____ Fire Pump Power Devices ____Water temp Devices ____ Room Temp Devices ____ Pump Running Devices ____Water Level Devices ____ Other Monitored Suppression Systems (ie - Hood Suppression System) _____________________________________________________ Copyright 2007 3 Revised 05/21/2007 UL Form No. CS-ASD-FAS
MANUAL FIRE ALARM AND GUARDS TOUR SUPERVISORY SERVICE Note: If proper number of fire alarm boxes required by Standard is not installed, show in deviations section. Quantity _______ Manual Fire Alarm Boxes (Pull Stations) _______ Guard Tour Stations _______ Combination Manual Fire Alarm and Guard Tour Stations ALARM NOTIFICATION AND ANNUNCIATION DEVICES Note: If quantity and location of notification devices does not comply with the Standard, show in deviations section. Quantity _______ Bells _______ Horns _______ Chimes _______Visual Signals Type: Light Strobe Graphic _______ Audible / Visual Signals Type: Light Strobe Graphic _______ Others: _____________________________________________________ EMERGENCY VOICE ALARM SERVICE Note: If quantity and location of devices does not comply with the National Fire Alarm Code or other NFPA 72-Series Standards, show in deviations section. Quantity _______ Voice / Alarm Channels _______ Speakers _______ Speaker Zones _______Telephone or Telephone Jacks Fire Service Copyright 2007 4 Revised 05/21/2007 UL Form No. CS-ASD-FAS
SYSTEM DEVIATIONS FROM REFERENCED NFPA STANDARDS Note: If service provided (i.e., periodic testing, maintenance, response, or coverage) is not in accordance with NFPA Standard specified, the details must be shown in this section. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ CONTROL AND TRANSMITTER UNITS Manufacturers and Model Numbers: Indicate model numbers and manufacturers of all control units and transmission devices. Do not include initiating device model numbers. Control Unit: Mfg: _______________________ Model _________________________ Independent Transmitter Mfg: _______________ Model: ________________________ (If applicable) ALARM TRANSMISSION METHOD Complete for all remote monitoring locations except NONE Multiplex ______ Direct Wire _____ Derived Channel _____ Remote Radio System _____ Radio Network/Transport System (Two Way) _____ Private Radio System _____ Radio Network/Transport System (One Way) _____ Digital Alarm Communicator _____ Cellular Digital Alarm Communicator _____ Transmitter (McCulloh) _____ Other Transmission Technologies _________________ Copyright 2007 5 Revised 05/21/2007 UL Form No. CS-ASD-FAS
Copyright 2007 6 Revised 05/21/2007 UL Form No. CS-ASD-FAS REMOTE MONITORING Monitoring Location: (Circle only one. Choose from UL Listed Central Station, Fire Department, Proprietary, Other or No Remote Monitoring). Indicate your choice by circling the appropriate form of monitoring. UL Listed Central Station File Number: ________________ Service Center Number: _________________ Company Name: _______________________________________________________________ City, State and Zip Code: ________________________________________________________ Fire Department Dispatch Center Name: _______________________________ (Use Address box at right) Proprietary Supervising Station Address: _____________________________ (Use Address box at right) Other Location As Approved by AHJ City, State and Zip: ____________________ (Remote Stations only) (Use Address box at right) Alarm Retransmission Method to Fire Department: Primary Secondary Code Transmitter ______ ______ Direct Telephone Line ______ ______ Public Telephone Network ______ ______ Private Communication System ______ ______ 911 Emergency Services NA ______ No Remote Monitoring (Local Systems)

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Cs asd-fas

  • 1. SN: Underwriters Laboratories Inc. 速 333 Pfingsten Road, Northbrook, IL 60062-2096 Phone: (847) 664-2645, Fax: (847) 407-1001 Fire Alarm System Description Worksheet PROTECTED PROPERTY Name: ________________________________________________________________________ Address: ______________________________________________________________________ City: ____________________ State: ________ Zip Code: ___________________ Representative Name (please print): ________________________________ ALARM SERVICE COMPANY File No: _____________________ Service Center Number: __________________ Name: ________________________________________________________________________ Address: ______________________________________________________________________ City: ____________________ State: _________ Zip Code: _________ Representative: Phone Number: Name (please print): __________________ ( ) ____________________ Representative Fax Number: Title (please print): ____________________ ( ) ____________________ PERIOD OF ISSUANCE Note: Issue date must be within the last 30 days or request cant be processed. Certificates may be issued from 1 to 5 years. Issue Date: ___/___/___ Expiration Date: ___/____/___ Old Serial Number (If applicable): _________________ New ________ Renewal _________ Replacement __________ Copyright 2007 1 Revised 05/21/2007 UL Form No. CS-ASD-FAS
  • 2. COMMENTS AND CLARIFICATIONS Note: Clarify location or area of coverage, as needed. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ AREA COVERED Note: Buildings, Floors or Area(s) should be listed here ______________________________________________________________________________ ______________________________________________________________________________ ALARM SYSTEM DESCRIPTION SYSTEM TYPE System Type: System is installed and maintained in compliance with Standard identified. Type NFPA Edition Year (Circle One) (Circle One) Central Station NFPA 71 or NFPA 72 __________ Local NFPA 72 or NFPA 72A __________ Auxiliary NFPA 72 or NFPA 72B __________ Remote Station NFPA 72 or NFPA 72C __________ Proprietary NFPA 72 or NFPA 72D __________ Authority Having Jurisdiction, i.e., Requiring Certification (List Below): ______________________________________________________________________________ Responding Fire Department (List Below): ______________________________________________________________________________ Date of Periodic Test Agreement: _____ / ______ / ______ (mm/ dd / year) * Please note a testing and maintenance contract date is required. Copyright 2007 2 Revised 05/21/2007 UL Form No. CS-ASD-FAS
  • 3. AUTOMATIC FIRE DETECTION AND ALARM SERVICE Type Description (Circle One) Total Detectors are installed in all areas, rooms, and spaces as defined in Standard NFPA 72 or NFPA 72E (National Fire Alarm Code) Chapter 5. Selected Area Same code requirements as total coverage but protection is only provided for specifically defined area(s) of the protected property. In addition selected coverage may include smoke detection at control units. Must describe details in Comments and Clarifications Section. Partial Deviations from Total or Selected Area Coverage. Protection provided is less then required by the code in some way. Number of devices and locations shall be specified. Must describe details in System Deviations Section. Quantity Quantity Quantity Quantity Smoke Detectors _____ _____ Ion _____ Photo Duct Detectors _____ _____ Ion _____ Photo Heat Detectors _____ _____ ROR _____ Fixed Temp _____ Combination Other: _____ Details: ________________________________________________________ SPRINKLER SYSTEM WATERFLOW ALARM AND SUPERVISORY SERVICE Note: If all sprinkler risers and water shutoff valves are not supervised, show in deviations section. Type of System: _____Wet Pipe _____Dry Pipe Quantity _______ Waterflow Switches (Includes water pressure type) _______ Sprinkler Valve Supervisory Switches Other Supervisory Services: Quantity Quantity Quantity ____Water Pressure Devices ____Air Pressure Devices ____ Fire Pump Power Devices ____Water temp Devices ____ Room Temp Devices ____ Pump Running Devices ____Water Level Devices ____ Other Monitored Suppression Systems (ie - Hood Suppression System) _____________________________________________________ Copyright 2007 3 Revised 05/21/2007 UL Form No. CS-ASD-FAS
  • 4. MANUAL FIRE ALARM AND GUARDS TOUR SUPERVISORY SERVICE Note: If proper number of fire alarm boxes required by Standard is not installed, show in deviations section. Quantity _______ Manual Fire Alarm Boxes (Pull Stations) _______ Guard Tour Stations _______ Combination Manual Fire Alarm and Guard Tour Stations ALARM NOTIFICATION AND ANNUNCIATION DEVICES Note: If quantity and location of notification devices does not comply with the Standard, show in deviations section. Quantity _______ Bells _______ Horns _______ Chimes _______Visual Signals Type: Light Strobe Graphic _______ Audible / Visual Signals Type: Light Strobe Graphic _______ Others: _____________________________________________________ EMERGENCY VOICE ALARM SERVICE Note: If quantity and location of devices does not comply with the National Fire Alarm Code or other NFPA 72-Series Standards, show in deviations section. Quantity _______ Voice / Alarm Channels _______ Speakers _______ Speaker Zones _______Telephone or Telephone Jacks Fire Service Copyright 2007 4 Revised 05/21/2007 UL Form No. CS-ASD-FAS
  • 5. SYSTEM DEVIATIONS FROM REFERENCED NFPA STANDARDS Note: If service provided (i.e., periodic testing, maintenance, response, or coverage) is not in accordance with NFPA Standard specified, the details must be shown in this section. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ CONTROL AND TRANSMITTER UNITS Manufacturers and Model Numbers: Indicate model numbers and manufacturers of all control units and transmission devices. Do not include initiating device model numbers. Control Unit: Mfg: _______________________ Model _________________________ Independent Transmitter Mfg: _______________ Model: ________________________ (If applicable) ALARM TRANSMISSION METHOD Complete for all remote monitoring locations except NONE Multiplex ______ Direct Wire _____ Derived Channel _____ Remote Radio System _____ Radio Network/Transport System (Two Way) _____ Private Radio System _____ Radio Network/Transport System (One Way) _____ Digital Alarm Communicator _____ Cellular Digital Alarm Communicator _____ Transmitter (McCulloh) _____ Other Transmission Technologies _________________ Copyright 2007 5 Revised 05/21/2007 UL Form No. CS-ASD-FAS
  • 6. Copyright 2007 6 Revised 05/21/2007 UL Form No. CS-ASD-FAS REMOTE MONITORING Monitoring Location: (Circle only one. Choose from UL Listed Central Station, Fire Department, Proprietary, Other or No Remote Monitoring). Indicate your choice by circling the appropriate form of monitoring. UL Listed Central Station File Number: ________________ Service Center Number: _________________ Company Name: _______________________________________________________________ City, State and Zip Code: ________________________________________________________ Fire Department Dispatch Center Name: _______________________________ (Use Address box at right) Proprietary Supervising Station Address: _____________________________ (Use Address box at right) Other Location As Approved by AHJ City, State and Zip: ____________________ (Remote Stations only) (Use Address box at right) Alarm Retransmission Method to Fire Department: Primary Secondary Code Transmitter ______ ______ Direct Telephone Line ______ ______ Public Telephone Network ______ ______ Private Communication System ______ ______ 911 Emergency Services NA ______ No Remote Monitoring (Local Systems)