9803 19TH AVE SE 2018-01-02 MF Import

DISTRIBUTOR CERTIFICATION INSTALLATION-INSPECTIONFOR ANSUL R-1001 OR R•102 RESTAURANT FIRE SUPPRESSION SYSTEM Customer Name I, t Address 3 �� f �,.�-purr- )+�.,�/ c-v�,hc-rr . _ur+ . SYSTEM ONE Model A-VjSul_. 2 IUa. Number of nozzles and Part No. � e4 rnlc2•' �� "i / r.t /,11 r JV L, IJ M07 7 L f. Number of detector(s) and degree rating r62177 SUo',C- LcrK. Energy shut-off devices - type and size Other accessory equipment provided COOKING/VENTILATING EOUIPMENT r Number of duct(s) and size �'+� I a x IS Plenum Size- /D X % Cooking Appliances and size (NOTE: List appliances from left to right) SYSTEM TWO Model 4J� Lj. 103. ? O o MU,#'j UL�r- G//C-P� li L 700 Number of nozzles and Part No. trl c7 l C 103:4 A f ` / t I Al /Jrlszr-� /� ✓�1 Number of detector(s) and degree rating .SJp',c NSd L r k Energy shut -of devices - type and size AOltf V,4LOr r"� Other accessory equipment provided �s^GRo St &r' r CAL r'•t eGT[f-u� "rtEr✓t COOKING/VENTILATING EQUIPMENT _r• Number of duct(s) and size / - tl . " Plenum Size Cooking Appliances and size (NOTE: List appliances from left to right) TO BE COMPLETED BY INSTALLER AYES O NO The fire suppression system is installed in accordance with the manufacturer's instructions, NFPA Standard 96, 17 and 17A (current issue), and all applicable state and local codes. It is a requirement of the manufacturer and recommendation of the National Fire Protection Association that the fire system be Inspected and maintained every 6 months for proper sys- tem operation. Exceptions to other provi§ions of NFPA 96 that were observed are noted below. n YES ❑ NO YES ❑ NO Exceptions: IN All electrical work or work provided by others to complete systefn installation Copy of owner's manual left with owner. INSTALLER NAME EL 4f-' '71Y-"1Z-Z SIGNATURE DISTRIBUTOR r rA-�. r 77)- 6_ s ADDRESS /61-! SLi DATE i //X/A Pv No. 2470-00 C1290 wormYO U.S., InC Um9 i U.S.A.