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PIPER FIRE PROTECTION INC. : . <br /> 13075 US_:HWY 19:NORTH <br /> -SUPPR SISION SYSTEM . <br /> :.CLEARWATER,FL 33764 <br /> e r CERTIFICATE OF. <br /> (800)327-7604 . <br /> PIPERFIRE.COM <br /> FICB PI'OteCt1011:. INSTALLATION <br /> .COMPLETION- <br /> customer./Job Name. Publix#1245 a Hawkings Construction <br /> Contractor Nam <br /> Address 7838 Gall Blvd .. <br /> • <br /> PO.No:, - <br /> City yState/.Zip Zephyrhilis, FL 33541: _ .. : JC No. 10-30-02127:. <br /> ANSUL DISTRIBUTOR(To complete-this section), <br /> Date installation-Completed Installer Name <br /> Distributorship,:. Piper Fire Protection <br /> Address :13075.US-HWy:19 N .. . <br /> city j state Clearwater, FL.33764 <br /> To Be Completed by.Installer <br /> 11 Yes ❑ . No The restraint fire suppression system is UL300 listed.and installed in accordance with the manufacturer's <br /> instmaions,*6 suppression:system requirements of NFPA Standards 96 and 17A(current issue),and.all: <br /> I�. Yes t7 ; ,No L� GI1lciertifythat.ONLYgenuineANSULFactory SUPPLIED components.and <br /> ap I a cod <br /> (Installer Signature) extinguishers specified are used,and.that.UL"Classified generic parts were not - <br /> substituted: <br /> Iff Yes: ❑ No: All electrical work or work provided by others to complete system installation is completed. <br /> 9: .Yes _. ❑ .No A copy of the owner's manual has been left With owner: <br /> EXCEPTIONS <br /> Note exceptions to other provisiori of NFPA 96 of NFPA 17A.that were observed: <br /> TEST INFORMATION <br /> ❑ AHJ TesCNOT Required' ❑ AHJ Signature REFUSED <br /> ❑ Site Witnessed,System Checkout Procedure Testing Date'of Verbal AHJ Approval . <br /> Name Signature .. <br /> Position- <br /> Date, <br /> ❑ Test Pending (8f Testing Complete <br /> Anticipated Test Date AHJ Signature&Date Below <br /> AUTHORITY HAVING J RISDICTION (AHJ) _To complete this section <br /> AHJ Name(Print) <br /> AHJ Si nature / <br /> . g <br /> Date <br />