HomeMy WebLinkAbout18-20287 CITY OF ZEPHYRHILLS
5335-8TH STREET
(813)780-0020 20287°
COMM EXHAUST HOOD/DUCT PERMIT
PERMIT INFORMATION. -.. - LOCATION INFORMATION
Permit Number: 20287 Address: 5039 1 ST ST
Permit Type: FIRE COMM EXH HOOD/DUCT ZEPHYRHILLS, FL.
Class of Work: FIRE-HOOD SUPPRESSION SYS Township: Range: Book:
Proposed Use: COMMERCIAL Lot(s): Block: Section:
Square Feet: Subdivision: CITY OF ZEPHYRHILLS
Est. Value: Parcel Number: 10-26*21-0010-12800-009
Improv. Cost: 2,400.00 OWNER INFORMATION
Date Issued: 9/28/2018 Name: J & G RESTAURANT PROPERTIES LLC
Total Fees: 130.00 Address: 20015 TAMIAMI AVE
Amount Paid: 130.00 TAMPA, FL. 33647-3368
Date Paid: 9/28/2018 Phone: (813)713-0094
Work Desc: INSTALLATION SUPPRESSION SYSTEM THE GREAT CATCH
CONTRACTORS APPLICATION FEES
STATE FIRE PROTECTON I C FIRE PERMIT FEES 50.00 FIRE INSPECTION FEES 30.00
FIRE PLAN REVIEW FEES 50.00
FIRE LIGHT TEST-Final Ins ections Re uire
Chapter 633, Florida Statutes,authorizes the City to charge and collect user fees to pay for the costs of fire
prevention and protection related activities such as inspections, plan review,administrative fees, and other
costs related to the aforementioned.
Complete Plans, Specifications and Fee Must Accompany Application. Commencement of work without written approval of
the Fire Department's Fire Marshal or required permits or opening up for commercial activity without an approved final
inspection shall be charged double permit fee per day of operation or a minimum of$100.00, whichever is greater. All
work shall be performed in accordance with City Codes and Ordinances.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN
FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT."
CONT CTOR SIGNATURE PERMIT OFFICER
P RMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
ZEPHYRHILLS FIRE RESCUE DEPT- 813-780-0041
813-780-0020 City of Zephyrhills Fire Fax-813-780-0021
Permit Application
Date Received Phone Contact for Permit
Owner's Name /�� G�i1-2/47�C� 1� Owner's Phone Number
Owner's Address ^b q 1 S r 5 �--
Fee Simple Titleholder Name Titleholder Phone Number
Fee Simple Titleholder Address
Job Address j D 3 S/ S/ ze 1'-1/1 f `f 335-)d— Lot#
Sub Division F Parcel#
Bio-Hazard Waste Storage-ANNUAL Fumigation Tent
Comm Exhaust Kitchen Hood/Duct Hazardous Material(Tier II or RQ Facility)ANNUAL
Controlled Bum Hood Installation
Emergency Generator<30 kw LP/Natural Gas-Installation
Emergency Generator>30 kw LP/Natural Gas-ANNUAL Sale
Fire Protection Maintenance-ANNUAL Places of Assembly-ANNUAL
try emi ®n ter
Sprinkler 1:1 ❑ ❑ ❑ Recreational Bum ^7 v �
Fire Alarm ❑ ❑ ❑ Sparklers L
Hood Cleaning � ❑ ❑ ❑ � � Sprinkler System Installations
Hood Suppression ❑ ❑ ❑ Standpipes(Sprinkler Sys)
Fire Alarm Installation Torch Roofing/Tar Kettle
El Fire Pumps Waste Tire Storage ANNUAL
Flammable Application-ANNUAL Valuation of Project
Fuel Tanks �(
Q Other:
Contractor l Company F/lc� T�ZJ70 57✓
Signature f Registered Y/N Fee Current Y/N
Address License# �- erc,
ELECTRICIAN Company
Signature Registered Y/N Fee Current I Y/N
Addressl License#
PLUMBER I Company
Signature Registered Y/N Fee Current Y/N
Address License#
MECHANICAL Company
Signature Registered Y/N Fee Current Y/N
Address License#
OTHER Company
Signature Registered Y/N Fee Current Y/N
Address License#
Directions: E
Fill out application completely.
Owner&Contractor sign back of application,notarized(Or,copy of signed contract with owner)
If over$2500,a Notice of Commencement is required(Mechanical work over$5000)
Supply two(2)sets of drawings with applicable documentation
Allow 10-14 days for review after submittal date. Parcel#-obtained from Property Tax Notice(http://appraiser.pascogov.com)
NOTICE OF;DEED RESTRICTIONS: The undersigned understands that this permit may be subject to"deed" restrictions"
which may be more restrictive than County regulations. -The undersigned assumes,responsibility for compliance with any
applicable deed restrictions."
UNLICENSED CONTRACTORS AND CONTRACTOR RESPONSIBILITIES: If the owner has hired a contractor or
contractors to undertake work; they may be required to be licensed in accordance with state and local regulations. If the
contractor is not-licensed as required by law, both the owner and contractor may be cited for a misdemeanor violation
under state law. If the owner or intended contractor are-uncertain as to what licensing requirements may apply for, the
intended work,they are advised to contact the Pasco County Building Inspection Division—Licensing Section at 727-847-
8009. Furthermore, if the owner has hired a contractor or contractors, he is advised to have the contractor(s) sign .
portions of the "contractor Block" of this application for which they will be responsible. If you, as tl4e owner sign as the
contractor, that maybe an indication that he is not properly licensed and is not entitled to permitting privileges in Pasco.
County.
CONSTRUCTION LIEN LAW(Chapter 713, Florida Statutes,as amended): If valuation of work is$2,500.00 or more, I
certify that 1, the applicant, have been provided, with a copy of the "Florida Construction Lien Law—Homeowner's
Protection Guide" prepared by the Florida Department of Agriculture and Consumer Affairs. If the applicant is someone.
other than the`owner", i certify that i have obtained a copy of the above described document and promise in good faith to
deliver it to the'owner"prior to commencement.
CONTRACTOR'S/OWNER'S AFFIDAVIT: I certify that all the information in this application is accurate and
that all work will be done in compliance with all applicable laws regulating construction, zoning and land
development. Application is hereby made to obtain a permit to do work and installation as indicated. I certify
that no work or installation has commenced prior to issuance of a permit and that all work will be performed to
meet standards of all laws regulating construction, County and City codes, zoning regulations, and land
development regulations in the jurisdiction. I also certify that I understand that the regulations of other
government agencies may apply to the intended work, and that it is my responsibility to identify what actions I
must take to be in compliance.
If I am the AGENT FOR THE OWNER, I promise in good faith to inform the owner of the permitting conditions set forth in
this affidavit prior to commencing construction. I understand that a separate permit may be required for electrical work,
plumbing, signs, wells, pools, air conditioning, gas, or other installations not specifically included in the application. A
permit issued shall be construed to be a license to proceed with the work and not as authority to violate, cancel, alter,:or
set aside any provisions of the technical codes, nor shall issuance of a permit prevent the Building Official from thereafter
requiring a correction of errors in plans, construction or violations of any codes. Every permit issued shall become invalid
unless the work authorized by such permit is commenced within six months of permit issuance, or if work authorized by
the permit is suspended or abandoned for a period of six(6)months after the time the work is commenced. An extension
may be requested,, in writing, from the Building Official for a period not to exceed ninety (90) days and will demonstrate
justifiable cause for the extension. If work ceases for ninety(90)consecutive days,the job is considered abandoned.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT
WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOU,RNOTICE OF COMMENCEMENT.
FLORIDA JURAT(F.S.117.03)
OWNER OR AGENT CONTRACTOR
Subscribed and swom to(or affirmed)before me this Subscribed and sw to ad)before e,this
by by
Who is/are personally known to me or has/have produced Who is/are personally known to me,ot ave produced
as identification. as identification.
Notary Public Notary Public
Commission No. Commission No.
Name of Notary typed,printed or stamped Name of Notary typed,printed or stamped
s
City of Zephyrhills
BUILDING PLAN REVIEW COMMENTS
Contractor/Homeowner: c�`�0.'t�- kept
Date Received: 9—
Site: 5051 13 l
Permit Type:
Approved w/no comments: Approved w/the below comments: ❑ Denied w/the below comments: ❑
This comment sheet shall be kept with the permit and/or plans.
C 2 ld
Gene Brown—Fire Safety Officer Dhte Contractor and/or Homeowner
(Required when comments are present)
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PYRO-CHEM®
PrQ■ KITCHEN-KNIGHT®n - KITCHEN
y P-�-1 soi30014601600 KNIGHT I I.:
Chem NOZZLE COVERAGE SUMMARY SHEET
Width' Length or Min- -Max. `
Nozzle Flow in. (cm) Area sq in Height Height
Appliance Type Points Max:Side (cm2) to. (cm) in. (cm)
Deep Fat Fryer-Vat 2H 2 191/2 19 in. 24 J61)-. 48 (122) .
Deep Fat Fryer(Low Proximity)'-Vat 2L (49.5) (48 cm) 13 (33) 24 (61)
Deep Fat Fryer-Drip Pan•(Vat 18 in.x 18 in.max.(45.7 cm x 45.7 cm)) 2H 2 27 3/4 500 24 (61) 48 (122)
Deep Fat Fryer(Low Proximity)-Drip Pan (Vat 18 in.x 18 in. max.(45.7 cm x 45.7 cm)) 2L (70:5) (3225.8).- 13. (33) 24 (61)
DeepFatF yer-Drip Pan ,at 191/2 in.x 19 in.max-(49.5 cm x 48.3 cm)), 2H'"` 2 25 3/8 495 24 (61) 48 (122)
=- - -
Deep Fat Fryer(Low Pro)imity)-Drip Pan(Vat 191/2 in.x 19 in.max(49.5 cm x 4U cm)) 2L (64.5) (3193.5) .-.13 (33) 24 (61)
Two Burner Range: 1 H J 1 12 28 in. 40, (102)'" 50. (127)
Two Burner Rarige(Low Pro)imity) 1 L (30.5) " (71 cm) 13 (33) ._ 24 (61).
Two Burner-Back Shelf(High Proximity) 2L . 2 28 (71) 336.(2167.7) 24 (61) 35. (89)
our Burner:Range. . 2L 2 28 (71) 28 in.(71 cm) 34 .(86). 48 (122)
~Small Wok 1H 1 24 in.dia. 6 in.depth 24 (61) 48 (122)
Small Wok(Low Proximity) 1 L (61 cm) (15.2 cm) 13 (33) 24 _ (61)
Large,Wok . -211 30 in.dia. 8 in.depth 24 (61) 48 _ (122)
2 . .
Large Wok(Low Proximity) 2L (76.2 cm) (20.3 cm) 13 (33Y 24 (61)
SmaII Griddle 1H'; 1 36 . .1080 24 " (61) 4&- (122)
Small Griddle(Low Proximity) 1 L (91.4) (6968) 10 (25) 24 (61)
��. Large Griddle 2H 2 48 1440 24 (61) -48 (122)
Large Griddle(Low Proximity) 2L (122) (9290). 10 (25) 24- (61)
'Gas Radiant Char-Broiler I 1 26. 624 24 _(61) -48 (122)-
Gas Radiant Char-Broiler(Low Proximity) 1 L (66) (4025.8) 13 (33) . 24 (61)
Large Gas Radiant Char-Broiler 2H 2 36 864 36 (91) 48- (122)
Large Gas Radiant Char-Broiler(Low Proximity) 2L (91.4) (5574) 13 .(33) 36 (91)
Lava Rock Char-Broiler 2L, 2 26 (66) 624 (4025.8) 15 "(38)- 35 (89) "
Natural Charcoal Char-Broiler(max.fuel depth 6 in.(15 cm)) 1 H 1 24 480 24 (61) 35 (89) " -
Natural Charcoal Char-Broiler(Low Proximity) IL (61) (3096.8) ' 15 .(38) 24 (61)
Mesquite Char-Broiler(max.fuel depth 6 in:(15 cm)) I 1 24 480 24 (61) 35 '(89j ;
Mesquite Char-Broiler(Low Proximity) 1 L" (61) (3096.8) 15 (38) .24 (61)- .
Upright/Salamander Broiler 1 L 1 36 in.width 28 in.-dia. Front edge;
(91.5.cm) (71 cm) above the grate
Chain Broiler(Internal Chamber) :1 L " 1 27 in.-width 38 in.dia. Front edge;1-3 in.
(68.5 cm) (96.5 cm) (2.5-7:5 cm)above chain.
Tilt Skillet/Braisirig,Pan Coverage limitations are based on fryer sizes.including the drip boards.
Exception:Tilt Skillets and Braising Pans may exceed maximum of 6 W(0.56 mz)
Nozzle Flow Width Length Nozzle Placement(See
5 Ploy nnm Type Points tt (m) ft (m) manual for more detail)-
'SingLe.6ankNyt3a� $�1H��I 1 4 (1.2) 10. (3) 0-6 in:(0-15.25 cm)
from end of plenum
Nozzle Flow Max.Side Perimeter . Diameter Length"
'duct" " Type Points in. (cm) in. (cm). in. (cm).
Rei angie/Circular`')j 2D':J r 2 34- (86) 100 (254) 31718.(81) Unlimited
Rectangle/Circular (2)2D 4 61 (129.5) 150 (381) ,4T1/2(121) ; Unlimited
Rectangle/Circular 1L 1 - 163/4(42.5) 50 (127) 16" (41) Unlimited
PC2001189(6p ,..,..
:PYRO-CHEM® .
0 KITCHEN.KNIGHT@ 11 KITCHEN /
Pyr ' PIPE VOLUMES . KNIGHT® I I
= Chem CONVERSION CHART
► 1/4 in.=26.5 ml per ft -3/8 in.=37.5 ml per ft 1/2 in.=59.8 ml per.ft 3/4 in.=105 ml per ft.
Total. 1st Nozzle Total Pipe Maximum Pipe Length From 1st Nozzle to Last Nozzle Maximum Pipe.Length
Cylinder- Flow Pipe -to Last, 114 in: 3/8 in. 112 in. 3/4 in.; 114 in: 3/8 in. 1/2 in. 3/4 in:
Size. Pis Vol Nozzle ft (m) ft (m) ft (m) ft (m) " ft - (m) ft- (m) ft (m) - ft
PCL 160 5 1500 600 ' 73.1 (22.3) 40.0 (12.2) 25.0 (7.6) - 29.2 (8.9) 16.0 (4.9) 10.0 (3) -
.CL3W 10 .1910 1125 93.2 (28.4) 50.9 '(15.5) 31.9 (9.7) 18.2 (5.5) 54.9 (16.7) 80.0 (9.1) 18.8 (5.7) 10.7 (3.4)'
PCL 460 14 3400 3000 165.9 (50.6) 90.7 (27.6)- 56.9- (17.3) 32.4 (9.9) 146.3�(44.6) 80.0 (24.4) 50.2 (15.3) 28.6 (8.7)
PCL 460- 15 2600 , 2000 126.8 (38.7) 69.3 (21.1) 43.5 (13.3), 24.8 (7.6). '97.6 ..(29.7) 53.3 (16.3) .33A (.10.2) 19.1' (5.8).
PCL 600 , 19 '4215 1688/side 205.6.(62.7) 112A (34.25) 70.5 .(21.5) 40.1 (12.2) 82.3 (25,1) 45.0 (13.7) 28.2 (8.6) 16.1• (4.9) . .
PCL600 20 3465 1312.5/side 169.0 (51.5) RA (28.1) 57.9 (17.6) 33.0 (10) 64.0 (19.5) 35:0 (10.7) 22.0 (63) 12.5 (3:8)
Pipe Length -Volume of Agent.per Pipe.Length/Size Minimum Pipe Volumes for a Fryer,Range,and Wok
it . (m) 1/4 in. -3/8 in. 112 in. 3/4 in. 'Cylinder Size Entire System At or before appliance.
-1 0.30 20.5 =.. 37.5 59.8 105 PCL 160 239 ml 1 Flow Pt 180 ml-1 Flow Pt
2 0.61 41 75 119.6 210 PCL 300 300 ml-4 Flow Pis. 239 ml-2 Flow Pis
3 0.91 61.5 .. 112.5 179.4 315 PCL 460 660 ml-10 Flow Pis 180 ml-2 Flow.Pis
4 (1.22). 82 150 2392 420 PCL 600 960 ml-14 Flow Pis 120 ml-2*Flow Pis
`5 1.52 102.5 187.5 299 525 .
6. 1.83 123 225 358.8 630
-7 2.13 143.5 262.5 418:6 735
8 2.44 164" 300 478.4 840
9. 2.74 184.5 337.5 538.2 945
10 3.05 205 375 598 1050
- 11 3.35 .225.5 412.5- 657.8 1155
12 3.66 246 450 717.6. 1260
13 3.96 266.5- 487.5 777.4 1365 .
14 ' 4.27 287 525 " 837.2 1470
15 4.57 307.5 562.5 897. 1575
'16 4:88 328 600 . 956.8 1680
17 5.18 348.5 637.5 1016.6 1785
18 5.49 369 675 1076.4 1890
19 (5.80). 389.5 712.5 1136.2 .1995
� 20. (6.10) 410' 750 1196 2100
General Rules:
1. Measurements taken from fittings centerline(All SCH:40 Pipe).
`2. Maximum difference in elevation from valve outlet to any nozzle is 10 ft(3.05 m).
3, Largest diameter pipe must be used first and decrease in size as installation moves away from the tank.
4. No traps in the piping.
5. Two elbows are allowed in place of a swivel.Elbows used as,a swivel do not have,to be subtracted from the total allowed.
6. Maximum of 25 elbows.
7. Maximum of 5 elbows between nozzle and preceding tee.
8: Maximum flows for 1/4 in.pipe=6 flows. -
9. Maximum volume allowed for 1/4 in-pipe from tee to nozzle is 410 ml(20 ft or 6.10 m).- -
Additional rules for PCL 600:
1. Split piping must be used-with a maximum of 14 flows on a side.
2. No nozzles before the split.
3. Minimum 1/2 in.pipe must be used to the first split.
ZEPFIYRHILLS FIRE DEPARTMENT
38410_:6th Ave:Zephyrhills- FL,: 33542.: : °
FIRESERVICE USER FEES increase 1/1/2018
Occupancy_No::
Plan"No:e Contractor
_ 12P 2r
".
Business [Name:. . 2 Billing Address:
Bu.siness'Address::
Business'Phone:No.: Billing Phone No.:
Business'Fax.No:: Billing Fax No:
Contact:'. Contact:
PLAN.REVIEW FEES INSPECTION.FEES PERMIT FEE". ." "
:Annual- : . . . . . . . . . . . . . . .
Education,healthcare,De•
tention&Correctional Public
Assembly,Business, : schools;
Storage,Mercantile and Churches
Site Plan N/C Industrial: no charge Sprinkler_ $50. ,
Multi-Family/Commercial: : :03 sf up.to 800 sq.ft $: ".24.00 Standpipes $50 .:
.(Minimum Charge$24.00- , . 861:=1,500 sq.ft. : $ 34.52 Fire Pump
:Plan Revisions: DBL. 11501--2,500 sq ft. $: :60.02.: Hoods: .$50
2,501-3,500 sq ft $ 90.02 'Fire Alarm: .$50
SPRINKLER SYSTEMS:: 3,501:5,-000 sq ft $ 127 52 LP"Gas : _ $50 . -
0-26 Heads, : $50 5;501-7,500.sq ft '• : '$. : 187.52. : Natural.Gas .$50:
26 plus Heads $100. : 7;501,10,'000 sq ft' $ 262.52' Fuel Tanks; per.tank. : $50
STANDPIPE.SYSTEM 10,001=15,000 sq ft '. ' " :$ " 375.02 Sparklers : $1,00
.Per .Riser $50 15,001-20,000 sq ft $ 525:02' Fire'Works. $500 .
:FIRE PUMP 20,001=30,000 sq ft . $ : 750.02 Camp,Fire(eecreation _-$25
Per'Pump- $100 30;001-40,000 sq ft $ 1.,050:02 Controlled Bu da 100
FIRE ALARM SYSTEM_ 40,,001=60,000 sq ft $ 1,500.02 Hoo $50
0.25 Devices $50 60,001-80,000 sq ft $ 2;100:02' Place of Assembly. $50. Annual.
80,00.1-($2,1.00;02)pe[ .
26 plus_Devices $100 "ea add 1',OOQsq ft $ 0.06 Fire Protection $25
PPRESSION SY (Busines's closed.until Flammable Application $50 : Annual
et - . violations-corrected).. Waste Tire Storage $50_ annual . . . .
Dry: ... ..$50 . : SPRINKLER SYSTEMS : : Generator<.KW $100
CO2 $50 Hydro.Undergrounds $45 Generator>30KW. $100,
Other .$50. :Hydrostatic Test : $65. per system: Bio,Hazard Waste $100 Annual
KITCHEN;EXHAUST AcceptanceTest. $45 per system Fumigation:Tenting .$50.
E] Hood/Ducts $50: Hydrant Flow: $75' Torch Pot/Applied "$50
OTHER Haz.Materials $50, :Annual'.
LP Installation per tank $50.: FIRE ALARM'SYSTEM
Fuel Tank Installation $50. System:Acceptance $50. "
(Per Tank) $50 a Recall Acceptance $50
❑Natural Gas Installation ' $50 OTHER
'(Per System) Fire Wall/Smoke Wall - $15 perwall
'Spray Booth $50 LP Gas pertank'
Natural Gas" . $25. : . per system. .
Tent.10'x10'"orgreate'r. $'15, per tent . .. . .
Fire Pum
Sir .Su ression
Syste
H'!Exhaust Hood/Duct $30.
:Re-inspection DBL
(other:than:ann ual);
Inspection scheduled. DBL:
and cancelledless than: -
24,hours
Cohsttuction Ihsp. N/C
Emergency Vehicle Acce $50 .
PLANS TOTAL. INSPECTION TOTAL. PERMIT,TOTAL
GRAND.TOTAL
Comments:
Date: . Inspector:-
see back:
mn.
FALSE ALARM FEE
1st Alarm N/C
2nd Alarm• : N/C. .
3rd Alarm: . N/C:
4th Alarm $100
5th Alarm: : $150
6thAlarm. $200
NO COMPLIANCE $150• -
.font.Annual Inspection Fees
3-11.,Units price per unit $ 5.36 .'
12-25 Units:price per unit $ 4.82, : . . . " . . . .
26-50:Units price per unit . . $ 4.29
51-100 Units.price per unit :$ .3.75.
100 or more Units price per unit $ 2.68
Fire Safety,re-inspection types
First Re-inspectiol N/C
Second re-inspect $75
Third re-itispectior_$: 125.00
Inspectidn scheduled but cancelled 24.hrs: $. 50.00.
TOTAL
AM
,09/26/2018 08:41AM 7275276285 CANDHINSLIRANCE PAGE 01/01
ACC HATE(MMIDDIYYYY)
1r+" R CERTIFICATE OF LIABILITY INSURANCE 9/26/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO R1014TS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY.OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ,
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED .
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder Is an ADDITIONAL,INSURED,the policy(ies)most ba endorsed. if SUBRor;ATION IS WAIVED,subject to
the terms and conditions of the pollCy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in Ileu of such endomement(s).
PRODUCER DAVID H MYER, AGENT NONT6 GT David prayer. CERTIFICATE; ITTCTORIA OR AtDNDA
Commercial And Hoare Insurance, Inc, PND� �. (727)527-5700 �AC.No):t72!)027-6285
5635 49th Strait N Mnssvbadhanan or aacheaffer @cahinsurance.00m
INSURERS)AFFOROING COVERAGE ` ,NAIC 0 St Petersburg FJ4 33709 INSURERA:CERTAIN UNDERWRITERS Al2 TtAOY173
INSURED ^_'- INSURER B. -- LONAON
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SThTE FIRE PROTECTION INC / Theodore MaCeae .,.
P O Box 5354 INSURERD:
INSURERfi:
TAMOO FL 33771-5354 INSURER Ft
COVERAGES CERTIFICATE NUMBER:CL17103101799 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PER100
INDICATED. NOTWITHSTANDING ANY RRQUIREMENT•TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR N1AY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
_ EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LJUL I TYPEOPINSURANCE i+OLIC1rNUMHER ULIC YY�YY OL D LIMITS
OOMMSRdAL GENERAL
LIABILITY EACH OCCURRENCE S 1,000,000
A �CLAIMS MODE f RA X OCCUR i pR MISER 9. �...50,000
k66000210-00 11/1f2017 11/1/2018 MEDEXP(Any0M r� $ 51000
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE , _
S POLICY a JECOT 7 LOG PRODUCTS-COMPIOP AGO i$ _2,000,000
(OTHER: E w
AUTOMOBILE LIABILITY M INi3LE LIMIT $
ANY AUTO BODILY INJURT(P9,
ALL OWNED SCHEDULED BODILY INJURY Mor WiOnt) S r
AUTOS AUTOS _
HIRED AUTO NoN.OWNED PR4PE�— •-l.-_... _..
I .S
UMBRELLA LM OCCUR i EACH OGCURFtI NCE $
EXCESS LIAB CLAIM$4v1A0E AGGREGATE $
DEC).I I RETE T10N$ l _ $
WORKERS COMPENSATION ,OTH-
ANDEMFLOYGFWUABIUTY YIN STATUTE
ZANY PROPMETOR/PAWNERGXECUTIVE ON IA
A
E.L.EAC•y ACCIDENT S
(M�dallry In NAderCERIMEMSER F7CClUDED7 _r0 s
yy 5, E.L.DISFA9E•EA Efdlri.OYE $
ES RIPTION F OPERATIONS DMOW E.L DISEASE-POLICY LIMB t
I
t5E$C1 IPTION Of OPERATIONS(LOCATIONS I VEHICLE$(ACORU 101,Addillwml Romkrkll S01114014,may D4 At4ched It mom spaco Is required)
INST4%ZL 6 SERVICE FIRE EXTINGVISHXJF$
CERTIFICATE HOLDER CANCEL. TIO
(613)78D-0021
SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITIX Or L'EPHYRRILLS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
5335 8TH STREET ACCORDANCE WffH THE POLICY PROVISIONS.
SLPHYRHILLS, FL 33542
AUTHORIZED REPRESENTATNE )
01988.2014 ACORD CORPORATION. All rights reserved,
ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD
1NS026(201401)
Sep 26 18 12:30p State Fire Protection Inc 7277248643 P.1
ti
JIMMY patmnts Cula Sinco
CHIEF FINANCIAL OFFICER BUREAU CKIZF
jeflug Halal Keith McCarthy
DIMION'DMECTOR SAFETY PROGRAM MANAGER
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF STATE FIKE MARSHAL
20D East Gaines Street -TW1d=ec Florida 3239M342
Tel.850-413-3644 Fax.850-410-2467
ME EQUIPMENT DEALER LICENSE
OFFICIAL COPY
THIS CERTIFIES THAT:State FIRE PROTECTION Inc.
1744 12TH St SE 93
LARGO FL 33771
QUALIFIER: Theodore J Macejak
Has Complied with Florida statutes and has qualified for the type and class shown here on to service,
repair,install or inspect all tripes Pre-Engineered Fire Extinguishing Systems.Excludes any service,
gul
recharge,repair,installation or inspection of any type of Halon System.
Issue Date: 01/01/2018
Typo- 07
Claw. 04
County: Pinellas
License/Penrnit* 028234-0003-1987
Expiration Date. 12131/2019
Chief Financial Officer
CERTIFICATE OF LIABILITY INSURANCE DA 9/26/2018
09/26r'201 B
i THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTEA CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on
this certificate does not confer rights to the certificate holder-in lieu of such endorsement(s).
PRODUCER CONTACT ,Julie Hollingsworth
NAME:
Stahl&Associates Insurance Inc, PHONE (863)688-5495 1 FAX (863}688 4344
C No Fed: AMC No
91 Lake Morton Drive AAREss: julie.hollingsworth@stahlinsurance.00m
P 0 Box 3608 WSURERt(S)AFFORDING COVERAGE NAIC N
Lakeland FL 33802 INSURERA- Bridgefield EMPloyerS InS Co 10701
INSURED INSURER B
State Fire Protection Inc INSURERC•
PO BOX 5354 INSURER D:
INSURER E:
Largo FL 33779 INSURERF:
COVERAGES CERTIFICATE NUMBER: 18-19 WC Master REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI00
INDICATED. NOTVVITHSTANDINGANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TOALL THE TERMS,
EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I EXP
1TR TYPEOFWSURANCE VVVD POUCYNUMBER W EFF Wpm LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S
CLAIMS-MADE OCCUR PREMISES Es occunencel 5
M ED EXP Any one person s
PERSONAL&ADV INJURY S
GEN'LAGGREGATE LIM17APPUES PER: GENERALAGGREGATE S
POLICY JEOa F-1 LOC PRODUCTS-COMPIOPAGG $
OTHER: S
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 3
e accident
ANYAUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accideml $
AUTOSONLY AUTOS
HIRED NON4W4EO PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Peredenl
5
UMBRELLALIAB OCCUR EACHOCCURRENCE $
EXCESS UAB CLAIMS-MADE AGGREGATE 5
DED RETENTION 3 5
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY YIN STATUTE RH
ANY PROPRIETORIPARTNERIEXECl1TIVE EL.EACHACCIDENT $ 100,000
A OFFICERIMEMBEREXCLUDEDT NIA 083028591 02I08/20t8 02/08120t9
(Mandatory InNIt EL.DISEASE-EAEMPLOYEE S 100,000
If yes,describe under
DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT S SOO,OOD
DESCRIPTION OF OPERATIONS 1.LOCATIONS!VEHICLES(ACORD 101,AddlMonal Remarks Schedule may beaKsched III more space is required)
i
i
CERTIFlCATE HOLDER CANCELLATION
SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
City of Zephyrhills ACCORDANCE WITH THE POLICY PROVISIONS.
5335 Bth St
AUTHORIZED REPRESENTATIVE
Zephyrhills FL 33S42
01988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(20161`03) The ACORD name and logo are registered marks ofACORD
L-d £b99VULZL Out Uoi;Oa;OJd en j elelS d99:Z L 9 L LZ deS
_ _ }
i .. _. -..
.. ,,.� .' �/�QJ, .. '... . . ..
Pre-Engineered Restaurant Fire Suppression Systems Report
SERVICE COMPANY DATE OF SERVICE TIME � A.M. P.M.
ANNUAIB : SEMI-ANNUAL I RECHARGE INSTALLATION RENOVATION
STATE FIRE PROTECTION INC ,
17 4 4 12 T H S T R E E T S E N°3 LOCATION OF SYSTEM CYLINDERS UL 300
LARGO FL 33771 ves NO
7 2 7 - 7 9 7 -2 H 6 4 MANUFACTURER MODEL NUMBER WET DRY CHEMICAL
S T A T F L IC . 02823400a31987 r; /X/1 '` -
SjAjE L IC , 02823400Q � 198 ] fey;V"' r ✓ r
CYLINDDE/R'SIZpE MASTER CYLINDER SIZE SLAVE CYLINDER SIZE SLAVE
4-. f t
CUSTOMER FUSE LINKS 360°F. FUSE LINKS 450°F. FUSE LINKS 500'F. OTHER
Name f'.�°'r°/;�i?,',��i" r . ���r__'r' "
FUEL SHUT-OFF ELECTRIC GAS SIZE
Ad dress
SERIAL NUMBER LAST HYDRO TEST DATE LAST RECHARGE DATE
City Stater ZIP.s "- y
MANUFACTURER'S MANUAL REFERENCE
1
Telephone Store No. ,7t 4-7
PAGE NUMBER: DRAWING NUMBER.><,,jt' DATE .V f i f i
Owner or Manager A
COOKING APPLIANCE LOCATIONS: LEFT TO RIGHT
Y 1 `' L2 4 {�(1" ,kn �` 1 1 ,,,•ta c'
?'.v �`{.✓lt�.ti��--Y 4 �!
1. All appliances properly covered w/correct nozzles 20. Replaced fuse links &?' �
2. Duct and plenum covered w/correct nozzles 21. Check travel of cable nuts/S-hooks
3. Check positioning of all nozzles. ~•4- 22. Piping&conduit securely bracketed
4. System installed in accordance w/MFG UL listing 23. Proper separation between fryers&flame
5. Hood/duct penetrations sealed w/weld or UL device "r 24. Proper clearance-flame to filters eAF
6. Check if seals intact, evidence of tampering 25. Exhaust fan in operating order
7. If system has been discharged, report same 26. All filters in place °
8. Pressure gauge in proper range(If gauged) 27. Fuel shut-off in on position '
9. Check cartridge weight(If applicable) 28. Manual&remote set/seals in place
10. Hydrostatic test date ' 29. Replace systems covers
11. 6 year maintenance date 30. System operational&seals in place
12. Inspect cylinder and mount f 31. Slave system operational �r
13. Operate system from terminal link !fit 32. Clean cylinder&mount
14. Test for proper operation from remote 33. Fan warning sign on hood
15. Check operation of micro switch 34. Personnel instructed in manual operation of system :
16. Check operation of gas valve 35. Proper hand portable extinguishers
17. Clean nozzles `-` 36. Portable extinguishers properly serviced x
18. Proper nozzle covers in place 37. Service&Certification tag on system
19. Check fuse links and clean AIA NOTE DISCREPANICES OR DEFICIENCIES BELOW A ,(,r�
COMMENTS- _
On this date,-this pre-engineered fire suppression system was inspected and operationally tested in accordance with the fire
suppression system requirements of NFPA17 or 17A, 96 and the manufacturer's manual with the results indicated above.
X ;� iY'r,9'?y:���C f��/G`r•,���.i�/'`7�;r /?il'�� %�•.1��� ;`�
SERVICE TECHNICIAN PERMIT NO. DATE: TIME: - AM PM CUSTOMER'S AUTHORIZED AGENT
The above service technician certifies that the system was personally inspected and found conditions to be as indicated on this report.
AUTHORITY HAVING JUMSDICTION