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Home My WebLink About14-15436 - CITY OF ZEPHYRHILLS � 5335-8TH STREEr <sis»so-oozo '15 6 PIRE SPRINKLER SYSTEM PERMIT Parmit Numbar: '15436 Addrgss: 38250 A AVE Parmit TypB: FIRE SPRINKLER SYSTEM ZEPHYRHILLS. FL_ Class of Worlc: FIRE-SPRINKLER SYS TownsF�ip= Range- Book: Proposgd Usa= COMMERCIAL Lot(s): BIocK- SBCtion- Square Faet= Subdivision: CITY OF ZEPHYRHILLS Est_ Valug: Parcel Numbgr= '14-26-2'I-00'IO-O'1300-00'10 Improv_ Cost= '14,'166_48 �ata Issued: 6/27/20'14 Name: ZEPHYR HAVEN NURSING HOME Total Fees: '145.00 Address: 38250 A AVE Amount Paid= '145.00 ZEPHYRHILLS, FL. 33542 �ate Paid: 7/02/20'14 PF�one: (407)975-3000 Worlc Uesca INSTALL SPRINKLER HEA� IJN�ER AWNING OUTSI�E PER AHCA REQIJIREMENTS 5 . 5 _ FIRE INSPECTION FEES 45.00 �r�� ! ` � FIRE ACCEPTANCE Final CF�apter 633� Florida Statutes�authorizes tF�e City to oharge and col�cct user fees to pay for the oosts oF Fre prevention and protection related activities such as inspec[Gons� plan review�administrative fees�and other costs relaied to ttie aforementloned. Complete Plans, Specifications and Fee Must Accompany Application. Commencement of worlc without written approval of the Fire �epartmenYS Fire Marshal or required permits or opening up for commercial activity without an approved Fnal inspection shall be charged double permit fee per day of operation or a minimum of$100_00, whicF�ever is greater_ All worlc shall be pertormed in accordance with City Codes and Ordinances_ "WARNING TO OWNER: YOUR FAILURE TO RECOR� A NOTICE OP COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY_ IF YOU INTEN� TO OBTAIN FINANCIN � CONSULT WITH YOUR LEN�ER OR AN ATrORNEY BEFORE RECOR�ING YOUR NOTICE OF COMMENCEMENT_" - l-��9.-�� -- ` ONTRACTOR SIGNATURE PERMIT OFFICE PERMZT EXPIRES ZN 6 MONTHS WITHOUT APPROVEO INSPECTION CALL FOR INSPECTION - 8 HOURS NOTICE REQUIRE� ZEPHYRHILLS FIRE RESCUE �EPT- 513-780-0041 s�3-7ao-oo20 Ciry ot Zephyrhills Fire Fax-913-78p-0021 Permit Application Dete Receiveaf �r `� Phone Gonlact far Permit 2 . . s�:�-w,.,�.,q.—,...�.n..�--,.-..-.,..�9�a�:�!*�n»m�rc�.�m�,.-,-�.�-n.M::,x«�er+��'�- . _ a, .. e�as•�4�z�,s�-� « Owners Name Zephyr Haven Rehabilitation pwner's Pfione Number �� c�rs ada�$s 3825Q A Ave Zephyrhills, FL 33542 l=ee Simple TiUehalder Name 7itleholder Phon�Number � � � Fee Slmpie Tft�eFwider Address Job Address Lot# � Sub Division Parc:ei# Q Bio-Nazarc!Waste Siorage-ArINUAL Q Fumigaticn Tent � Comm ExFraust Kitchen Haod/Duct Q Mazardaus Material(Tfer II or Rp Facility)ANNUAI. � Controiled Bum a Nood instaitatian � Emerge�y Ge�er�tor<3Q kw Q LP/Natural Gas-Inslalladan � Emergency Generator>30 kw o LPlNetural Gas-ANNUAi.3ate � Fire Protection Mainlenance-ANNUAL Q Places ot Assembly-ANNUAL 'C[�y emi � er SpriMcie� � O Q O � Ftecreatlanst Bum Fire Alartn � f7 ❑ O � � Sparklers Hood Geaning � ❑ CJ O � � Sprinkier System Instaliations � f �� Nood Suppressfon � C} Cl O � � Standpipes{Sprinkler Sys) � Rre Alarm Instaliation � Toroh RooflnglTar KetGe � Fire Pumps � Waste 7'Ire Storage ANNUAL Fire Works FlammableApplicatiora-ANNUAL r $14,16, 6.48 1 Valuation of Project Fuxel Tank& �. � Other. Instailation o approximate (26 sprin er heads under autside awnin s per AH requ�rements. CanVactar �Da�Y gig�� Reg;stered Y 1 N �ee cument Y!N Address License# ELECTRICIAN Company Signature Registered Y/N Fee Current Y/N Address �icense# PLUMBER �PanY gi9�t� Registenad Y/N Fae Current Y/N Address license# MECHANICAL �r4 Company g;g�� Registered Y/N Fee Cwrent Y f N Address Ucense# OTHER ��►P��Y Signature � Registered Y/N Fee Curront Y/N p��s liCense# �� I�r,: ._t �—Ss� n^- � �sm a..-m+. �r'a+�° _ .;?�`�., ..f -.'— ^�as '—"--�"e�' '�--�m•��t�.�.3�p,-�+^_ ,. CH(6Ct10f1$: Fiil out ap�piication compietely. dvmer&Contractor sign back of appiicetion,natari�d(th,copy of signed contract with owner) N aver$2500,a Na6ice ot Commencement fs required(Mechanical work over�6000) St,�pply txro(2)sets of drawings with applicabie documentation Albw 10-14 days tor review after submiltai date. Par�ce)#-oblained from Property Tax Notice(httpJ/appraiser.pascogov.com) NOTICE OF DEED RESTRICTIONS: The undersigned understands thet this permft msy be subject to'deed'restrictions" which may be more restrictive than Counry reguletforu. The undersigned assumes responsibility for compliance with arry apptksabl�deed resMctlons. UNLICENSHD CONTRACTORS AND CONTRACTOR RESPONSIBILITIES: If the owner has hired e contractw or contractors to undertake work,they may be required to be licenaed In acoordance with state and lopl regulaUons. H the contractor ts noi Ikensed as requfred by law, both the owner and contractor may be cited for a miademeanor violation under state law. If the owner ar inkended contractor are uncertain as to what licensing requkemerrts may epply for the intended work,they are advisad to oontact the Pasoo Courrty Buildinp Inspedion Division--Lfcensing Section at�27-847- 8009. Furthermore, if the owner has hlred a contractor or rxntrectors, he is advlsed M have the contracxnr(s) sign portlons of the'contractor Block'of this applicaHon for whfch it�y wNl be respons�le. If you,as the owner stgn es the contractor,ihat may be an indication that he is not properly licensed and is not eMided to permftdng priv8eges fn Pasco County. TRANSPORTATION iMPACTNTIUTIE3 IMPACT AND RESOURCE RECOVERY FEEB: The undersigned understends that Transportedon Impact Fees end Rac�urse Recovery Fees may apply to the construc8on of new bu�dings,che�ge oi use�existing buiidings,or expansfon of exis8ng buildings,ae spec�ied in Pasco County Ordinsnce number 89-07 and 90-OT,as amended. The undersigned also understands,that such fees,as may be due,wql be identifled et the time of permitting. It 1s further understood thai Transportadon Impact Fees end Resource Recovery Fees must be paid prior to recehrtng a'certificate of ocxupency"or flnel power rolease. If d�e pro)ect does not invdve a certiflcete of occxipar►cy or finel power relesse,the fees must be paid pnor to permit Issuance. Furthermore,If Pasco County WatedSewer Impact fees are due,they must be paid prior to permft issuance in accadance wtth appi�eble Pasco County ordinences. CONSTRUCTiON LIEN LAW(Chapter 713,Fb�ida Statutes,as amendsd): ff valuedon of work Is 52,500.00 or more,1 certly that I, tha applicent, have been provided with a copy of the 'Flo�ida Constructlon Lien Law—�iomaowner's Protedb�Guide'prepared by the Florida DepaRment of Agriculture and Consumer Aftairs. If the applicant is someone other than the'owner',I certify that I have obtained a copy of the above described dacument and promise in good faith to delfver ft to the'owner prlor to commencemerd. CONTRACTOR'SIOWNER'S AFFIDAVIT: 1 certKy that ail ihe Infamatton In this applicetlon is accurata and thet all work wAi be done in compliance wlth all appNcable laws�latlng cor�truc�on,zoning and land developmenL Appiication is hereby made to obtein a permit to do work and inetallatlon as indicated. I c�rrttify thet no work or Mstallation has commenced prlor to Issuance of a pemiit and that all work wBl be performed to maet standards of aq laws reguletlng oonstrucdon, County and Cih+codes, mning reguladons, and land development regulatlons In the jurisdidion. I also oerUfy thet 1 understand that the regulaUons of other govemment agendes mey apply to the intended vrrnic,and that�is my responsibility to identlry what actfons I must take to be in compliance. Such apendes indude but are not timfled to: - Department of Envkonmentel Protection-Cypress Bayheads, Wetland Areas and Ernirorxnentally Sensitive Lands,WetedWastewater TreatrnenG - Southwest Florida Water Management DisMct-Weiis, Cypress Bayheads, Wedand Areas, Akering Water�otxsea. - Army Corps of Engineers-Seawalls,Docks,Navigab�e Waterways. - Department of Health & Rehabllf�dve Servlces/Emrkonmental Health Unit-Weils, Wastewater Treatment, Sepflc Tanks. - US Environmental Protectfon Agency-Asbestoa abatemenL - Federal Avladon AuttwHty-Runways. I understand that the totlowing resUicUais appy to the use of fAl: - Use of f�l is not allowed in Fiood Zone'V'unlees expreasly permttted. - If the fl9 materfa! Is to be used in Flood Za� "A', ft is understood that a drainape plan addressing a 'compensating volume'will be submitted at time of permitt�g whkh�preparod by a professional engineer 1(oensed by tha State of Florida. - If the flN materfai is to be used In Flood Zone'A" in connecbon with a pertnitted building using stem wall conatrudbn,I certNy tl�at flll wdl be used oNy to flll the srea wffhin the stem waU. - If ftll materiel is to be used in arry area, I oertNy that use of such flll wBl not adversely effect edjacent propertles. H uee of flll is found to edversely aftect adjacent properdes,the owner may be dted for violsUng the conditlons of the building pertrdtt issued under the aHached pertnit�pplicaQon,for lots less than one(1) acre whlch are elevated by fAl�an en8ine�ed drek�age P�an is required. If I am the AGENT FOR THE OWNER,)promise In good faith to inform the owner of the permitting condiiio�s set forth in this sfNdavit prlor to commendng construction. 1 underotand fhat a seperate p�mit may be required for elecMcal wvrk, plumbMg, signs,w�elis, Pools, atr condiNoning, gas, or other InatallaBons not spedRcally h�cluded in the appik:atlon. A permit issued ahali be construed to be a Ifoense to proceed wkh the work end not ss authmilY to violete,cencel,elter,or �t eside am+provisions of the technk�i codes,nor shap fssuar�oe of s perm(t prevent the Buidirig OlKcial irom thereafter �1�9 a correctlon oi errors�plans,construction or vlolatfons of eny codes. Every permit issued sF�ail become irnaiid unless the work autFwrized by auch permit fa comme�ced with�n six moMhs of pertntt Issuance,or If work authorized by the pemdt Is suspended or abandaned ior a period of six(8)months aRer tF►e tlme the wmlc is commenced. M extension may be requested, in writing,irom the Buflding.OBidal ior a perlod not to e�c�nlnety(80)�ys end will demonstrate justifiable cause for the extension. If woric c�ses for nmety(90)co�sacutive days,the�b is considered abandoned. WARNING TO OWNER: YOUR FAH.URE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING,CONSULT n��n 70UR LEhDER OR AN ATTOR�lEY BEFORE FZ�OR ING YOUR NOTICE OF COMMEMCEMENT• Fl,ORipA JURAT(F.S.117.03) ONMER OR AOENT ��ro COIQTRA Su�d rid swom to(or afllrmed)b�(ors me tlib Subeaibsd ad�wom to(a ell�msd)bN«e me tlAa vN,o w.re P�known ro me or h�rtuve producad vVho Ware pasaneYY��or IwsRreve pod�psd as IdenYUcaeon. as Wx�ifiatlon. �,P� NobRy Pub9c Oo�rankslon No. Commbdon No. Nwns of Notary typsd.PAntod or stamPad Nune oi Nobry bP�.P��a�►^P� ' ZEPHYRHILLS FIRE DEPARTMENT 6907 Dairy Road, Zephyrhills, FL 33542 FIRE SERVICE USER FEES Occupancy No.: Plan No.: Contractor: Business Name: Billing Address: Business Address: Business Phone No.: Billing Phone No.: Business Fax No.: Billing Fax No.: Contact: Contact: PLAN REVIEW FEES INSPECTION FEES PERMIT FEE FALSE ALARM FEE 8 Site Plan N/C Annual N/C Sprinkler $50 1st Alarm N/C Mutti-Family/Commeroia� .06 sf 1st Re-inspection N/C Standpipes $50 2nd Alarm N/C (Minimum Charge$25.00 2nd Re-inspection $100 Fire Pump $50 3rd Alarm N/C �Plan Revisions DBL 3rd Re-inspection $250 Hoods $50 4th Alarm $100 4th Re-Inspection $500 Fire Alarm $50 5th Alarm $150 SPRINKLER SYSTEMS (Business closed until LP Gas $50 6th Alarm $200 -25 Heads $50 violations coRected) Natural Gas $50 NON COMPLIANCE $150 26 plus Heads $100 SPRINKLER SYSTEMS Fuel Tanks- per�ank $50 STANDPIPE SYSTEM Hydro Undergrounds $45 Sparklers $100 �Per Riser $50 Hydrostatic Test $65 per system Fire Works $500 FIRE PUMP Acceptance Test $45 persystem Camp Fire $25 � Per Pump $100 Hydrant Flow $75 Controlled Bum $100 FIRE ALARM SYSTEM Hood/Duct $50 0-25 Devices $50 FIRE ALARM SYSTEM Place of Assembly $50 Mnual 26 plus Devices $100 System Acceptance $50 Fire Protection $25 SUPPRESSION SYSTEMS Recall Acceptance $50 Flammable Application $50 nnnuai Wet $50 OTHER Waste Tire Storage $50 nnnuai Dry $50 Fire Wall/Smoke Wall $15 per wau Generator<KW $100 CO2 $50 LP Gas $25 per tank Generator>30 KW 150 Other $50 Natural Gas $25 per system Bio-Hazard Waste $100 a,nuai KITCHEN EXHAUST Fumigation Tenting $50 �Hood/Ducts $50 Tent 10'x10'or greater $15 per tent Torch PoUApplied $50 OTHER Fire Pump $45 Haz.Materials �100 nnnuai LP Installation per tank $50 Fire Suppression $30 Fuel Tank Installation $50 System Acceptance (Per Tank) $50 Exhaust Hood/Duct $30 �Natural Gas Installatlon $50 Re-inspection DBL (Per System) (other than annual) �Spray Booth $50 � Inspection scheduled DBL 8 and cancelled less than 24 hours Construction Insp. N/C Emergency Vehicle A� $50 FALSE ALARM PLANS TOTAL� INSPECTION TOTAL� PERMIT TOTAL.� TOTAL�— GRAND TOTAL Comments: Date: Inspector: mn City of Zephyrhills BUILDING FLAN REVTEW COMMENTS , Contractor/Homeowner: �1 r►`� ;� `�'1��-,� �r�Q f,� Date Received: �(l - 2-"1"-l 7' s�t�: 3��-5� � �-c� Permit Type: TJ C�C E'_M'�-a.T" �'��irtl��r~ x�c j �/�2C� Approved w/no comments:❑ Approved w/the below comments: Denied w/the below comments: ❑ ,..! f .>��51�-°�'` �.s ,,�'t�`� C��w.^� :�o% � P� ytole /f.�.S F r.�� . This comrnent sheet shall be kept with the permit and/or plans. `�a.,�zrv;-, ,.�c,�,ri.�'�.�c, JUN 2 5 2014 Kalvin Switzer-Plans Examiner Date Contractor and/or Homeowner (Required when comments are present) � �- co � . . �(,� Simp/exGr�nne// �� June 5'h, 2014 Jack J. Keith I I �/ /i�,� 1"'�/�s�E �" SimplexGrinnell LP /(/�'T � 4701 Oak Fair Blvd Tampa, FL 33610 � [��,�� iakeith(c�simplexqrinnell.com 2 e p � ' www.sim�lexqrinnell.com a � -.� gZ , SS� Neal Frasier Director of Plant Services � 38250 A Ave S �.��' Zephyrhills, FL 33542 �1 �j�� r �Q 'Jn neil.frasier@zephyrhaven.com ,� J� � ` � ✓�� Y� � (v 2�P�-i ✓ � RE:Zeahvr Haven-Fire Protection Additions I Mr. Frasier: Thank you for allowing SimplexGrinnell the opportunity to provide you with a proposal for the fire protection work as discussed. Due to the location of the work to be performed SG will most likely need to make a few site surveys. This will ensure that we are providing the most economical way to address the deficient items and cause the least amount of disruption to you daily activities. We will also need to coordinate the work with the local Authority Having Jurisdiction as to any permitting, shop drawing production, or hydraulic calculations that may be required. I assure you that we will perform these surveys in a timely manner and will get pricing back to you as soon as possible. I will contact you to set up our first site survey with my service supervisor. Regards, Jack J. Keith II Fire Sprinkler Sales Representative Safer Smarter. Tyco.TM' From:727552?475 To,8181378315$6 06106/2014 16 05 #500 P 033/073 [�EPAf�TMENT OF HEALTH RfVD HUMAN SERVICES FORtv1 APPROVED CENTERS FOR MEDIGARE $� MEDICAID SERVICES �MB NO 0938-0391 STATEMENF OF DEf1CIENG{ES (X1} PftOVtQERtSUPPLtEWCL1A {X2)MiJLTSPL�CONSTRUC730N (X3}pATE SURVEY AND PLAN OF CORREC710N IDENTIFICATION NUMBER: A.BUILDING 01-MAtPI FED COMPLETED 105658 g W�NG 05/28/2014 NAME OF PROVIDER OR SUPPIlER STREET ADDftESS,GTY,STATE,ZlP GQUE ZEPHYR HAVEN HEAL7H 8 REHAB CENT�R, INC �250AAVE ZEPHYRHILLS, F4. 33542 (X4)ID SUMMARY STATEMENT OF DEFICIENCIES ID pROVIDER'S PLAN OF CdRRECTION (X5) PREFIX {EACH DEFIClENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORFttCTNE AC i ION SHOU�D BE C.fJMPLETIpN 7AG REGlltATt7RY OR L$G IQENTIFYING fNFdRMATiON} i'AG CROSS-REFERENCED TQ TNE APPRQPRtATE onTE OEFIGIENCY} K 062 tYFPA 101 LIFE SAFETY CODE STANDARd K 062 SS=D Required autamatic sprinkfer systems are cantinuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6,4.612, N�PA 13, NFPA 25, 9 7.5 This STANDARD is not met as evidenceci by: Based on observatian and staff interview the faciiity�ailed ta ins#all and mainiain the requieed automatic sprinkler system in accordance with CMS S&G-4�-Q4, NFPA'fQ1 t2QOQ}, 19.3.5, 9 7 1, and NFPA 13, (1999), 5-13.8. Findings incSude� 1. On Q5128/14,fhe day af survey, abservatian during the concurrent interior and exterior tour from 9:45 a.m., to 1:00 p.m., accompanied by a facifity administrative ar�d a maintenance representative revealed four overhangs physically attached and extend'sng out from the buiiding 4 feet or more and not sprinklered. Staff interview of the facility maintenance representative revealed fhe four overhangs did con#ain cambustible material, (wood products), and were not sprinkEered by the a#tic sp�nkler system. The locations included, the overhang at the cou�tyard between khe Direct4r of Nursing's Office and the 3p0 corridor"Study", the averhang at the caurty�ard between the 300 corridor Dining Roam and the 200 carricior"S#t�ciy", th� �verhang at the caurtyard between the 200 corridar Living Room and the Activities Directors'O�ce on the 1 fl0 corridcar. The fourth averhang is located at the Labby exit between the Therapy Department and the 100 corridor Din�ng Raom. FORM CMS-2567(02-99)Prevlous Vsrslons Obsolete Event Ip;TLNV21 Facility ID:55111 If cOfl�lnuatiOn Sheel PBge 6 Of 8 From�727552147� To 81813783158G 06106/2014 16 06 #500 P.034/073 vcrr�rt�atcsv i vr ncr-ti��t-�r��v nv�vir��v �crtvtt.c� t-C1FtN1 At'Nt�UV�L} CENTERS FOR MEDICAR�& MEDICAID SERVICES OMB NO. Q938-0391 STATEMEt�FT`QF[3E�SCIEtJGIES (X'!} PROVIOERJSUPPG1Et:ICLIA {X2)MU�TtPIE COfJSTRUGTfON (X3}DATE SItRV£Y AND PLAN QF CORRECTION IDENTIFlCA710N NUMBER A BUILDING Oi•MAIN FED COMPLETED 105658 a.w�N� 0512$J2014 NAME OF PROVlDER OR 9UPPUER STI�ET ADDRESS,CITY,STATE,Z�R CODE ZEPHYR HAVEN HEAL.TH 8�REHAB CENTER, INC 38250 AAVE ZEPNYRHILLS,FL 33542 (X4)ID SUMMARY STA`fEMENT OF DEFIGlENCIES �p FR�VIDER'S PLAN OF GORRECTldN PREFIX (EACH DEFIGIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CqRRECTIVE ACTION SFIOULD D[ C01.�a�ETIpM TA� REGULATORY OR L.SC IDEN7'IFYING INFOF2MATtON) TAG CROSS-REFERENCED TO THE APPRpPRIATE DATE DEF1G!ENCY) K t}62 Continued Fram pac�e 6 K 062 2. On fhe day of survey the facility census was 111 residents. GMS S&C-09-Q4 NFPA 101 (2000), 19.3 5, 9.7.1 NFPA 13, (1999), 5-13 8 References: CMS S&C-09-04. On August 13, 2008, the Genters for Medicare 8� Medicaid Services(GMS� pubiished a final rule entit(ed "Medicare and Medicaid Programs; Fire�afety Requirements for Long Term Care Facilities,Automatic Sprinkler Systems " This regulation requires all long term care#acilities to be equipped with a supervised automatic sprinkler system byAugust 13, 2013, instafied in accordance with the 1999 edition af the National Fire Protection Assaciatian's (NFPA) "Standard for the Installation af Sprinkler �ystems" (NFPA 13�. NFPA 101 (2000), 19.3 5 Extinguishment Ftequirernents 19.3.5.1 Where required by 19.1.6, health care facilities shall be pratected thraughaut by an approved, supervised automatic sprinkler system in accordance with Sec�on 9.7. NFPA 101 (200fl),9 7.1 Automaiic Sprinklers. 9 7.1.1"` Each automatic sprinkler system required by anather section of this Code shail be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13,(1999), 5-13.8*Exterior Roofs or Canopies.5-13.8.1 Sprinklers shaii be i�stailed under e�erior roofs or canopies exceeding 4 ft (1.2 m)in width. F�cception:Sprinklers are permitted to be omittec�where the canapy or rorrf is of noncombustible or limited combustible construction. 5-13.8.2`Sprinklers shaSi be FORM GMS-2587(o2-sa)Previous versons Obsolete Event IO:TLNV21 FaclCrty ID:55111 If continuation sheet Page 7 of 8 From.72T5521475 To;81$137$315&6 0�/06I2014 16 06 #500 P 0351073 LiEPAK i MEN T OF HEALT�i RND HUMAN SERVIGES FORM APPROVEt� CENTERS Ft)R MEDICARE & MEDICAID SERVlCES C7M8 NC}. (}938-4391 STATEMEf1f'OP OEFIC(ENGtES (X9) PROVIDERJSUPPLIERJCi.lA (X2)MULTIPLE GONSTRUCTIQN (X3)DA7E StJRVEY AND PIAN OF CORRECTION 10EN71fICATION NUMBER A.SUILd1NG 01-MAIN FED COMPLETED 105658 B.WING U5l2812014 NAME OF PROVIDER OR SUPPLIER S7REET ApDRESS, CITY,STATE,ZIP CODE ZEPNYFt HAVEN HEALTH 8�REHAB GENTER,INC �250 AAVE ZEPHYRHILLS, FL 33542 (X4)ID SUMMARY S7ATEMENT OF DEFfCIENCIES ID PROVIqER'S PLAN OF CORRECTION (x5) PREFiX (EACN DcFICtEhlGY MUS7 SE PRECEC}EO BY FU1.! PREFIX {EAGH Ct?RF2EC7tVE ACTlON SHC?UGQ BE GO�tPtE7tON TAG REGULATORY OR LSC ID��(TIFYING INFOf=2MATI0N) 7AG CROSS-REFERENCED TO THE APPROPRIATE OATE DEFlClENCY} K 062 Gontinued From page 7 K p62 instalied under roofs or canopies aver areas where combustibles are sfared and hand(ed. FOf2M CMS-2567(02-{J�3)�'revious Versionc Obs:oiote Event 10�Tl.Mt21 �aality(!7 55511 If co�tlnuatian eheet Page 8 0!8 ■I SlmplearGtlnnel!LP t A761 Oak Fair Bivd. , . Tampa,FL 33610 U.S.A. TeL(St3}62fr5482 Fax(813}313-t606 PROP4SAL AND SER1/IGE AGRE'EMENT (SERVICE DEPARTMENT) SirnplexGrinnell Contract#: Salssperson. Date: SGOO65JK , Jack Keith June 20,2014 invaice To: 3ob Locat(an; Zephyr Haven Health and Rehab Same 38250 A Ave Zephyrh+tls,Ft�33542 Phone#: 813•7$2-550$ Fax it 407-200-8782 Gustamer P.O.# ATTN• Neai Fraiser DEFICIENCY REPAIRS PER THE UFE SAFETY INSPECTiON PERFORMED ON . SimplexGrinnell,for and(n consideration of ihe prices herein named,proppses to furnish the work,and/or materiais hereinafter described,subject to the Tetms and Conditions of thls Agreement. SCQPE OF WORK: Quote for labor and materia!to pertorm the following: -Install 20 pendant and 6 horizontal sidewall sprinkler heads in overhang exits as sited by IWCA. TERMS OF TH18 AGREEMENT ARE NET 10 NET 30 '' [] Ttme and Materlal ❑ Price Not To Exceed 0 Flxed Prlce of S 14,165.48 BAIANCE DUE IMPORTANT NOTICE TO CUSTQMER CUSTBMERAGCEFTA �t.+� �� ..�""�'�`' fn accepting ihh Agreeme u�Nomer�grea tar� md cond n oa#inM M»in indudinp#rose on the foitowing paqa(sy of this Agroament sM qny atWchmana or riGra ched hareto�hat taln sddNionat temq� ondlliom.It I�undarstuod thN thaq Uma and arrditio�ehaA prnall owr any varladon In terms an r,anditions pn arry purchas�order or othet doamenl Utat ths Cuslomer mry lseue.My charpes h the system requeated by tha Customer after tl»exeaSan of tbis Agraement sha!!be paid for by th�CusMrrwr and ancH cbsnpa shati b�wihwked�writing ATTENTION IS OIRECTED TO THE UMITATIpN Of WIBILITY,WAftRANTY,MtDEMNITY AND OTHER CONDRIqN3 CONifUNED IN THIS AG(�EMENT.Thls a11m cha11 be vok!if�ot accaptad in writing within qilrly�3Q)days kom Gu dsle 6n1 tel forth above. 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ZEPHYR HAVEN NURSING HOME �� - Aizheimer's and Related Disorders Unit OVERALL BUILDING PLAN ...,.,, ...,,.,.,,...,,�...... ..........�., ��,�.. .o...... ° �70 Avenue 'A' Zepnyrhilts,Florida 34248 — �--- - �--- - - i I FW: Message from"RNP617B36" https://acevxchch1001.sunbelt.org/owa/?ae=Item... FW: Message from "RNP617B36" Keith, Jack [jakeith@simplexgrinnell.com] Sent: Maiday,June?3,2014 3:28 PM To: Frasier,Neal Cc: Hicks,Vincent [vhicks@simqexgimell.com] Attachments:20140623151043575.pdf (403 KB) Neit, Ptease find the attached drawings for the proposed work. Regards, Jack J Keith II, ET / Fire Sprinkter Sates Representative / SimptexGrinnell Tel: +1- 813-626-5482 ext 233 / Mobite: +1-727-365-2232 / Fax: +1-813-313-1610 4701 Oak Fair Blvd / Tampa, FL 33610 / USA jakeith@simptexgrinnetl.com / www.simptexqrinnetl.com This email (including any attachments) may contain information that is private or business confidential. If you received this emait in error, please detete it from your system without copying it and notify sender by repty email so that our records can be corrected. Tyco' s vision is Zero Harm to peopte and the environment. Please consider the environment before printing this message. -----Originat Message----- From: Stricktand, Al Sent: Monday, June 23, 2014 3:27 PM To: Keith, Jack Subject: FW: Message from "RNP617636" -----Originat Message----- From: TAM292Scans@simptexgrinnel.com [maitto:TAM2925cans�simptexqrinnet.com] Sent: Monday, June 23, 2014 3:11 PM To: Strickland, At Subject: Message from "RNP617B36" This E-mail was sent from "RNP617636" (Aficio MP W3601) . Scan Date: 06.23.2014 15: 10:43 (-0400) Queries to: TAM292Scans@simptexgrinnel.com 1 of 2 06/23/14 15:48 Jacqueline Boges From: Frasier, Neal [neal.frasier@zephyrhaven.com] Sent: Thursday, June 26, 2014 10:22 AM To: Jacqueline Boges Cc: Kuhlmeyer, Richard Subject: RE: sprinkler inspection hi i will take color picture and print them out. so he can see them i will let ed know so he can install my new soffit thank you VERY MUCH neal From: Jacqueline Boges [jboges@ci.zephyrhills.fl.us] Sent: Thursday, June 26, 2014 9:49 AM To: Frasier, Neal Subject: sprinkler inspection Hey Neal did get with Bill and he said that he would have to look at the new sprinklers going in, but if you have pictures it would be no problem. Jackie Boges-SCSS 813-780-0020 ext 3513 Faith makes things possible...Love makes all things easy Dwight L. Moody i For Information Regarding this Report PRE-ENGINEERED • Please Call SYSTEM INSPECTION REPORT - 800-522-7150 Fir�eRMaster` SRO# 3 Date �j ` 2 � ^� ❑QUART RLY ❑ANNUAL ❑SEMI-ANNUAL ❑ NEW INSTALLATION ❑ FIRST INSPECTION ❑ CHANGES MADE Customer G � C rCU Customer# . Address � � �f � k ' T 1 ��,� J J Z Manager/Owner P one �� y ' � - System Location . � _ �� Manufacturer � G�2�y Model ' � � #Cylinders � - . Cylinder size(s) /�� List main cylinder size tirst 1� Method of Actuation Number Degree Last Hydro Q� Last Recharge � Serial Number �j � Fuel Type Restaurant Marine❑ Industrial ❑ Inspected per Installation Elec❑ Gas❑ Manual Date Size � ��. l � ?� � � g� � t �� . . _ . .. . . .. . � . ........... .. .. . �� ►� i , � � Y�-. . . .......... . .. ......... . ...... . . . . ............. �� .. ° z3 K 3 � �� 2 3 �{ 36 � z�f l I � � ( `� �, , 1 G � ��c�� Q �� C. YES NO N/A 1 Is system mounting bracket in ac ssible�cation and soundly mounted? � L ❑ � rblocka e? � � 2. Is piping tight,secured and checked fo, g 3. Are grease tights installed at all hood penetrations? � � 4 If multiple systems,did all systems operate satisfactory? � � � 5. Is system properly installed to properly protect hazard(s)? � 6. Are all nozzles properly located and proper type? � � 7 Is manual pull operational and in proper location? � � 8. Are all fusible links or HAD's of proper temperature rating? � � 9. Were fusible links replaced? � � 10. Is automatic detection operational? � � 11 Did fuel shut off properly? � � � 12. Did all e�ectnc shut down under hood(s)and alarms operate? � � � 13. Are bursting disc and chemical in good condition? .�` � � 14 Is cartridge within proper weight? �tl � � 15. Are all noules clean and caps/seals properly installed? � � � 16. Is cylinder pressure in operational range? � � � 17 Are filters clean and in good condition? � � 18. Was system placed back in service and in normal operation condition? ... � � � 19. Have persons working in area been instructed on proper operation of system? � � 20. Was the inspection/maintenance performed in accordance with NFPA 17,17A and 96? ❑ ❑ 21 Was inspection/maintenance performed in accordance with manufactures specifications? ❑ ❑ 22. Does system comply with UL300? � � 23. Was system tagged in accordance with 69A-21?(Florida only) � � Comments �, �` I,THE UNDERSIGNED,CERTIFY THAT I PERSONALLY INSPECTED TH OVE PREMISES AND FOUND CONDITIONS AS NOTED PermiVLicense�l Service echnic n Date Tim Customer Sign Date � � 3 � �,/ PM FL 1041 ( /12 Form X-PSI < i�`-!�'�'•'��'� ��F'�