HomeMy WebLinkAbout24-7647 (2)vggw ppa"'com � *
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Zephyrhills
a
City of Zephyrhilis
5335 Eighth Street !!TT!::
Zephyrhills, FL 33542 FIRE-007647-2024
Phone: (813) 780-0020 Issue Date:02/21/2024
Fax: (813) 780-0021
REINSPECTION FEES: (c) With respect to Reinspection fees will comply with Florida Statute 553.80(2)(c) the
local government shall impose a fee of four times the amount of the fee imposed for the initial inspection or
first remspection, whichever is greater, for each subsequent reinspection.
Notice: In addition to the requirements of this permit, there may be additional restrictions applicable to this property that
may be found in the public records of this county, and there may be additional permit required from other governmental
entities such as water management, state agencies or federal agencies,
"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."
Complete Plans, Specifications add fee Must Accompany Application. All work shall be performed in
accordance with City Codes and Ordinances. NO OCCUPANCY BEFORE C.O.
NO OCCUPANCY BEFORE C.O.
R SjG14ATURe PE IT OFFICE
I
IRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
LL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
813-780-0020 City of Zephyrhills Permit Application Fax-813-780-0021
Building Department
Date Received �GRO
rmickin9
�raat
Owner's Name POHIST IVlEDICALowner Phone Number
Owner's Address 315ARifET SCUAF UR,3542
Owner Phone Number
Fee Simple Titleholder Name owner Phone Number
Fee Simple Titleholder Address
JOB ADDRESS
381Q31ViA�2K SQUARE DR.,P1iYR111LLS, FL3354
LOT#
SUBDIVISION
PARCEL
(OBTAINED FROM PROPERTY TAX NOTICE)
WORK PROPOSED
NEWCONSTRF—IADDIALT
[ SIGN DEMOLISH
INSTALL
REPAIR
PROPOSED USE
SFR
COMM OTHER
TYPE OF CONSTRUCTION
BLOCK
E:]
FRAME STEEL
BUILDING SIZE
=BUILDING
ELECTRICAL
=PLUMBING
MECHANI CAL
=GAS
FINISHED FLOOR ELEVATIONS
1. •
ROOFING
FOOTAGE 13,175 1 HEIGHT
VALUATION OF TOTAL CONSTRUCTION
AMP SERVICE PROGRESS ENERGY W,R.E,C.
VALUATION OF MECHANICAL INSTALLATION
SPECIALTY = OTHER
FLOOD ZONE AREA =YES
Jed
gplae_�
No
BUILDER COMPANY
SIGNATURE [::::= REGISTERED ;;;�IEE �.RREN Y( N
Address ====== License #
ELECTRICIANE=::= COMPANY
SIGNATURE REGISTERED YiN FEE. CURREN YlN
Address License #
PLUMBERE=:== COMPANY
SIGNATURE REGISTERED Y 1 N FEE CURRENu Y I N
Address License#
MECHANICAL COMPANY E;
SIGNATURE REGISTERED Y (N FEE CURREN Y I N
Address License # =
OTHER Fire Alarm COMPANY Port Knox Fire Communications; Inc
SIGNATU REGISTEREQ Y / N FEE CURREN YIN
S_..®.....�,......e �..�_v.m.�. _
Address 5005 North Clark Avenue License # EF20Q00€ 76 ��
RESIDENTIAL Attach (2) Plat Plans; (2) sets of Building Plans; (1) set of Energy Forma; R•O-W Permit for new construction,
Minimum ten (10) working days after submittal date. Required onsite; Construction Plans, Stormwater Plans wl Silt Fence installed,
Sanitary Facilities & 1 dumpster, Site Work Permit for subdivisions/large projects
COMMERCIAL Attach (2) complete sets of Building Plans plus a Life Safety Page; (1) set of Energy Forms, R-O-W Permit for new construction,
Minimum ten (10) working days after submittal date. Required onsite, Construction Plans. Stonnwater Plans wl Silt Fence installed,
Sanitary Facilities & 1 dumpster, Site Work Permit for all new projects, All commercial requirements must meet compliance
SIGN PERMITAttach (2) sets of Engineered Plans:
****PROPERTY SURVEY required for all NEW construction.
Directions:
Fill out application completely,
Owner & Contractor sign back of application notarized
If over $2500, a Notice of Commencement is required. (AtC upgrades over $7600)
Agent (for the contractor) or Power of Attorney (for the owner) would be someone with notarized letter from owner authorizing same
OVER THE COUNTER PERMITTING (copy of contract required)
Reroofs if shingles Sewers Service Upgrades A/C Fences (Plot/Survey/Footage)
Driveways -Not over Counter if on public roadways -needs ROW
This space for use by Clerk of the C:irvuit Court only.
NOTICE OF COMMENCEMENT
11 '29 2 0 23 01 : 51, r; P A,-) # e , I
DS: 0,00 14J. it
NikKi
Permit Number:
Tax Folio No.
The undersigned hereby gives notice that improvements will be made to certain real; property, and in accordance with Section 713.13 ofthe
Florida Statutes, the following information is provided in the NOTICE OF`COMMENCEMENT.
38(03
1. Legal Description of property (street address required): hAartce# S ears iTrive e h chills Florida 33542
2. General description oftnprorements: Drywall, ceramic bile electrical lumbin casework and doors.
3a. Owner Name:
C)t�tier Address: � s 1l S" "�-
3b, Owner's interest in site:
3c. Fee Simple Title holder (of other than owocr)
Address:
a. Contractor Name_ �ogtaii Develo ers
Address 8624 US Flighwa 301 Riverview FI Phone: 813-352-6436
S. Surely Name: Anlounaol'beard:
Address: Phone:
6. Lender Name-, Contact:
Address: Phone:
7. Person within the State of Florida designated by owner upon whom notices or other documents may be served as provided by
Section 713.13(t Xp)7, Florida Statutes.
Name; Address:
Phone Number:
S. in addition to himself, Owner designates the following person to receive a copy oftbe Lienor's Notice as provided in Section
713, tat t)(b), Florida Statutes
Name: Address:
Phone Number:
9. Expiration hate of Notice ofC>onmaencement (expiration date is one (1) year from date of recording unless a different date is
specified).
WARNING TCD OWNER; ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THENOTICE OF iY1MMERCEME'.dT ARE
CONSIDERED IMPROPER PAYMEN"1's (IN DER CHAP`i'.ER 713. PART L SECTION 713,13, FLORIDA STATUTES, AND CAN RESULT IN YOUR
PAYING T4F`1C:E FOR IMPROVEMEN" TO Yttt7R PRtBPERT@: 4 NOTICE t?` CCSR9 FI NC'E 4iEhT MCtST BE &ECCiRIJEd3 AND POSTED ON THE
JOB SITE BEFORE 'T 3E FIRST INSPECTION. 1F YOU INTE\D Tit ORTAI ti N, 'C INGa CCa.' t;LT WITH YOUR LENDER OR AN ATTORNEY
BEFORE CONIMENC`IING WORK OR RECORDING YOUR tiOTIC� OF COMM
Signature of 0wrier or Lessee_ or O er"s or L see's authocizcd Ot ccrTn"cttar`ParInerlManager
Signator),'s Title/C3fizce
STATE OF FLORIDA
COUNTY Off' HILf,SBOROUGH
The foregoing instrumentwasacknowledge before me this
by t # ....... _.._ a5 . . G� Ior_ ._. .J !_ _ i. C
Personalty known .OR Produced Identification_
'Type of Identification Produced .
e.+agnarure - l'ututy ruum
Cinder penal 'es Perd I eclare fir w read the foregoing and that the facts started in it are true to fire beat of u+) kuoo ledge and belief,
SignatureoCfours rsonsignint Above'
OIEI
W COMMISSION 27E
(Acc�p.-of anp to dmus�iw um.�hccl as the llozc UrnWrQaihh of V#tas ticexi ufComereflaerucna) q'�. d 2'rSQY2tttF
� '" EXPIRES. ,My 7, 2027
813-780-0020 City of,Zephyrhilis Permit Application Fax-813-780-0021
Building Department
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 slate 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 the owner sign as the contractor, that may be an indication that he is not properly licensed and is
not entitled to permitting privileges in Pasco County.,
TRANSPORTATION IMPACT/UTILITIESIMPACT/UTILITIES IMPACT AND RESOURCE RECOVERY FEES: The undersigned understands
that Transportation Impact Fees and Recourse Recovery Fees may apply to the construction of new buildings, change of use in existing buildings, or
expansion of existing buildings, as specified in Pasco County Ordinance number 89-07 and 90-07, as amended. The undersigned also understands, that
such fees, as maybe due, will be identified at the time of permitting. It is further understood that Transportation Impact Fees and Resource Recovery
Fees must be paid poor to receiving a "certificate of occupancy" for final power release. If the project does not involve a certificate of occupancy or final
power release, the fees must be paid prior to permit issuance, Furthermore, if Pasco County Water/Sewer impact fees are due, they must be paid prior
to permit issuance in accordance with applicable Pasco County ordinances.
CONSTRUCTION LIEN LAW (Chapter 798, 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'SIOWNER'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 regulatingconstruction, 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 perfonued 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. Such agencies include but are not limited to:
Department of Environmental Protection -Cypress Sayheads, Wetland Areas and Environmentally Sensitive
Lands, Water/Wastewater Treatment.
- Southwest' Florida Water Management District -Wells, Cypress Bayheads, Wetland Areas, Altering
Watercourses.
Army Corps of Engineers -Seawalls, Docks, Navigable Waterways.
- Department of Health &" Rehabilitative Services/Environmental Health Unit -Wells, Wastewater Treatment,
Septic Tanks,
US Environmental Protection Agency -Asbestos abatement
Federal Aviation Authority -Runways,
i understand that the following restrictions apply to the use of fill:
Use of fill is not allowed in Flood Zone "W unless expressly permitted•
If the fill material is to be used in Flood Zone "A' it is understood that a drainage plan addressing a
'"compensating volume" will be submitted at time of permitting which is, prepared by a professional engineer
licensed by the State of Florida
If the fill material is to be used in Flood Zone "A" in connection with a permitted building using stem wail
construction, I certify that fill will be used only to fill the area within the stem wall,
If fill material is to be used in any area, l certify that use of such flit will not adversely affect adjacent
properties, If use of fill is found to adversely affect adjacent properties, the owner may be cited for violating
the conditions of the building permit issued under the attached permit application, for lots less than one (t)
acre which are elevated by fill, an engineered drainage plan is required,
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 Snot 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 0 OBTAIN FiNANCINO, CONSULT
FLORIDA JURAT (F.S. 117,03)
OWNER OR AGENT CONTRACTOR
Subscribed and sworn to (or affirmed) before me this b e d, sw orn to ( r ) for
b bv.T
Who is/are personally known to me or has/have produced Why /are one a e or has/have produce
as identification. as identification.
1 R
I•
Notary Public 0 Notary Public
Commission No, ommi $ion o.
Name of Notary typed, printed or sTamped Name of Notary t bed
Fiti 326572
Coporgissil
i2.; 2026
Fort Knox Fire & Comm unications, Inc.
005 N Clark Avenue 'Pampa, FL 33614 SILL �sr
1 Office: (813) 653-1605 Fax: (813) 653-1710 KNIGHT
by Honeywell
by Honeywell FL. license#: EF20000876 GA. License#: LUV406140 FarenhyV
72-33 ' FUNDAMENTALS OF FIRE ALARM SYSTEMS
FIRE ALARM SYSTEM ``RECORD OF -COMPLETION
To be completed by the system installation contractor at the time of systems acceptance and approval.
1. PROTECTED PROPERTY INFORMATION
Name of property: °s Florida Medical Clinic
Address: 38103 Market Square Dr. Zephyrhills, FL 33542 Perm t # 007 47 4
Occupancy type: -1 Business Description of property: ealth r
Name of property representative: Job # _ij(
Address:
Phone. Fax: E-mail:
Authority having,;urisdiction over this property:
Phone: Fax: E-mail:
2. FIRE ALARM SYSTEM INSTALLATION, SERVICE, AND TESTING il\'11aC}RMATION
Installation contractor for this equipment Fort Knox Fire & CommunicationsInc.
Address 5005 North Clark Avenue, Tampa.,FL. 33614
Phone: (13) 53-1605 Fax: (13) 653-1710 E-mail: sccalliras"1,1 a tkrzc�xf rexom
Service Organization for this equipment: Fort Knox Fire & Communications Inc
Address: 5005 N Clerk Aye, Tans a, FL., 3361
Phone: (813) 653-1605 Fax: $13 653-1710 E-mail: acoUins@ or°tknox ire.com
Location of as -built drawings: Close -Out Packy e Location of historical test reports: File
Location of system operation and maintenance manuals: Close -Out Packa e
contract for test 8c inspection in accordance with NFPA standards Chapter-10 is in effect as of:
Contracted testing; company:
Address:
Phone: Fax: E-mail.
Contract expires: Contract number: Frequency of routine inspections:
3. TYPE FIRE ALARM SYSTEM OR SERVICE
?VP'PA 72Chapter Reference of System Type:
Name of organization receiving alarm signals with phone numbers (if applicable):
f Alarm: I*- 'Trouble: Fe-, Supervisory:
Facility Name: Phone:
Facility Name: Phone:
Entity to which alarms are retransmitted phr°hills Phone:
Method of retransmission of alarms to that organization or location:
FIGURE 4.5.2.1 Record ref C'oniph--Won (2007 Ediflon) Y\114.4 72(pg.1 cif 5)
12.34 NATIONAL FIRE ALARM CODE .lob # .2 -003
3, 'TYPE OF FIRE ALARM SYSTEM OR SERVICE (continued) Permit # 007647-2024
If Chapter 8, note the means of transmission from the protected premises to the central station:
Digital alarm Communicator IP-Dact Multiplex F` 2-way radio N/A
f— A S Intelliiget j': Other:
3..1 System Software
Operating system (executive) software revision level:
Site -specific software revision date: Revision completed by:
„ SIGNALING LINE CIRCUITS
Characteristics g1'signaling line circuits connected to this system (see NFPA 72, Table 66.1):
Quantity: 1 Styr: y Class: B
. ALARM -INITIATING DEVICES AND CIRCUITS
Characteristics initiating device circuits connected to this system (see I'VFI'A 72, Table 65):
Quantity:. Style: Glass:
5.1 Manual Initiating Devices
5.1.1 Manual Pull Station Number of manual pall stations: 1
Type of devices: F*_ Addressable Conventional F Coded Transmitter F_ N/A
5.2 Automatic Initiating Devices
5.2.1 Area Smoke Detectors Number of Area smoke detectors: 0
'hype of coverage: Complete Partial area Selective Non -required
Type of devices: Addressable F_ Conventional Coded F_ Transmitter j N/A
"Type of smoke detector sensing technology: F_ Ionization I— Photo -electric F_ tither:
5.2.2 Duct Smoke Detectors r- Alarm r- Supervisory Number of duct detectors: 0
Type of coverage: Complete Partial area F Selective F*_ Non -required
Type of devices: F_ Addressable _ Conventional F_ Coded r- Transmitter Fe` N/A
5.2.3 Feat Detectors Number of heat detectors: 0
Type of coverage: F Complete Partial area F Selective 1r*_; Non -required
'type of devices: F_ Addressable F Conventional F Coded F Transmitter F*_ N/A
5.2.4 Sprinkler Waterflow Detectors Number of water flow switches: 0
Type of devices: F_ Addressable F_ Conventional F Coded F Transmitter F N/A
5.2.5 Alarm Verification Number of devices subject to alarm verification
Alarm verification on this system is: F Disabled F Enabled Set for seconds.
1' GUR 4.5.2.1 Record of C'onipletion (2007 Edition) NFPA 72(r)g.2 of 5)
72-135 NATIONAL FIRE ALARM CODE
Job # -003
Permit-# 007647-2024
. SUPERVISORY SIGNAL -INITIATING DEVICES AND CIRCUITS
6.1 Sprinkler System Number of valve supervisory switches:
Type of devices: Fi Addressable F Conventional r- Coded F Transmitter
F N/A
6.2 Fire _Pump
Type of fire pump: F Electric F Diesel
N/A
Type of lire pump supervisory devices: F Addressable F Conventional F_ Coded
F'; Transmitter
Fire pump Functions Supervised: f— Pump running Pump Phase Reversal F_ Primp Power off normal
F_ Low Fuel r@ Engine or control parcel trouble Selector switch not in auto
6.3 Engine -Driven Generator
f*_ N/A
Tape of generator supervisory devices: F_ Addressable F_ Conventional f— Coded
F_ Transmitter
Generator Functions Supervised: F Generator running Law Fuel ` Selector switch
not in auto
[_ Engine or control panel trouble F-Other:
7. ANNUNCIATORS
7.1 Annunciator 1 Local Rernote Location:
Type: F_ Adressable Directory ( Graphic [_0 N/A
7.2 Annunciator 2 1— Local F_ Remote Location:
Type: F_ Adressahle ( Directory Graphic N/A
7.3 Annunciator 3 F Local F_ Remote Location:
`Type: F_ Adressahle Directory Graphic r*7 N/A
8- ALARM NOTIFICATION DEVICES AND CIRCUITS ,
8.1 Emergency Voice Alarm Service
Number of speakers: - Number of multiple voice alarm channels:
re N/A
Number of single voice alarm channels: Number of speaker zones:
8.2 Telephone Jacks
Number of telephone jacks installed: Number of telephone handsets stored on site:
`type of telephone system installed: F_ Electrically powered F_ Sound Powered
f*_ N/A
.3 Non -Voice Audible System
Characteristics of notfflcation device circuits connected to this system (see NFPA 72, Table 65):
Quantity: Style: Class:
r; N/A
FI(z tTi E 4.5.2. d Record of Completion (2007 Edition) NJ, A4 72(pg.3 qJ'5)
72-36 NATIONAL FIFE ALARM CODE Job # -00
8. ALAltli'1NOTIFICATION DEVICES AND CIRCUITS UITS (continued) Permit # 007647-2024
8.4 Types and Quantities of Non -voice Notification Appliances Installed
Bells: With Visual device: Morns: With Visual device: 5'
Chimes: With Visual device: Speaker: With Visual device:
Visual devices without audible devices: 9 Other:
9. EMERGENCY CONTROL FUNCTIONS ACTIVATED
F_ Hold -open door releasing devices F7 Smoke management or smoke control F' Elevator recall
f Door Unlocking Other:
10. SYSTEM POWER SUPPLY
10.1 Primary Power
Nominal Voltage 120 Amps 20 Overcurrent protection type : —Breaker Amps
Location (of primary supply Panelboard): Electrical ClosetDisconnecting means location
10.2 Secondary Power
Location: FACP Type:. Batteries Nominal voltage: 24vdc
Number of standby batteries: 2 Amp hour rating: 7 fhr Current rating:
Calculated capacity of secondary power to drive the system: In standby mode: 26v c In alarm mode .2 vdc
Location of emergency generator: Location of fuel storage:. N/A
11.RECORD OF SYSTEM INSTALLATION
Fill out after all installation is complete and wiring has been eheckedfirr opens, ishorts, ground faults and improper branching, but before
conducting operational acceptance tests,
The system has been installed in accordance with the following NFPA standards: (Note any or all that aRplt,.)
f*— NFPA-72,National F"ire Alarm: Code [0—, NFPA,-70, National1,1ectrical C'ocle; .Article 760
Fe- Manufacturer's published instructions F- tither (please specify)
System deviations from referenced NFPA standards:
Signed: Nathc t{BU*t r Printed name: :than Burnside Date: 212712024
Organization: Fort Knox Fire and Communications Title: Installation Tech Phone: 813-653-16 i,5
12. RECORD OF SYSTEM OPERATION
All operational features and functions of this system were tested by or in the presence ofthe signer shown below, on
the date: shown below, and were found to be operating properly in accordance with the requirements of.
NFPA-72, National Fire Alarm £:ode F0_' NFPA-70, National Electrical Code. Article 760
Manufacturces published instructions f— Other (please specify):
Documentation in accordance with Inspection and Testing Form (Figure IO.62,3) is attached
Signed IV haiq/13t r Printed name: Nathan Burnside Date:
Organization: Fart Knox Fire and Communications Title: Installation Tech Phone: 813- 5 -16Q
F'IGUR 4.5.2.1 Record of C'ornpletion (2007 Edition) N1,711A 72(pgr.4 (af 5)
72-37 NATIONAL FIRE ALARM CODS Job # 24-003
Permit # 00 6 20
1Atv}�7'il�iCAT11�S AND APPROVALS
24
13,1 System Installation Contractor
This system as specified herin has been installed and tested according to all NFPA standards cited herein,
Signed: Nat t,'3 ?'-/ Printed name: NathanBurnside_Date: 212 12024
Organization: Fort Knox fire and Communications Title: Installation T ch Phone` 813.653-1605
13.2 System Service Contactor
This system as specified herin has been installed and tested according to all NFPA standards cited herein.
Signed: N 13 Printed name: NathanBurnside_Date: 212 12024
Organization: Fort Knox: Fire and Communications Title: Installation Tech Phone: 813-653-1605
13.3 Remote Station Monitoring
This system as specified herin will be monitored according to all NFPA standards cited herein.
Signed Printed naive: Date:
Organization: Title: Phone:
13.4 Property Representative
I accept this sys in as wing been installed tested toits specifications and all NFPA standards cited herein. ,
Printed name: 0 \jC to ate: - "Ze
1 Organization: Title: Phone: 01 -.5»
13.5 Authority having Jurisdiction
I have witnessed a satisfactory acceptance test of this system and find it to be installed and operating properly
in accordance with its approved plans and specifications, its approved sequence of operations, and with all NFPA
standards cited herin.
a�' Printed name.1 Date:�1
t�
Organizatiow 1611 Title: t 1.Phone p�
Z Ml-:;�
Notes:
:F`IGURE 4. Seta 1 Record of Cornplelion (20017 Edif on) NFP1# 72(pg. 5 of 5)
Revised 311 S,'2012