899 Atlantic Blvd NFPA-25 Inspection 613 N.W.MERCANTILE PLACE 3226 CHERRY PALM DRIVE
r TAMPA,Fill 33619
772-378-3350-FAX:772478-5967 81 3.630-0303-FAX;813-630l
PORT ST.LUCIE,134986 'm
113H DISTRIBUTION AVENUE WEST ""/W�AYNIE 4683 LAREDO AVENUE
JACKSONVILLE,FLORIDA 32266-2745 Automatic Fire Spriniclers, Inct FORT MYERS,FLORIDA 33906
906-268-3030-I":904-268H()724 222 CAPITOL CT. 239433-3030-FAX 239431
4370 MOTORSPORT DRIVE OCOEE, FL 34761-3033 3121 Nall 16TH TERRACE
CONCORD.NORTH CAROLINA 28027 407-656-3030-407-656-8026 POMPANO BEACH,FLORIDA 33064
704-782-3032-fifil 704�796-6838 954417-3030-1":954-917-9424
NFPA-25 Inspection, Testing and Maintenance of Wet Pipe Fire Sprinkler Systems
liberal an this form pointer 08 minimum rechannel of the current Supoptiod NITA 25 amps,for him Snunkler System conampand to datrituffloom symems and,pat supPlarnalmall
Wks or fire Pumps.Sep"a"a am available to Innate.win And human fire Pumps."by Wks and other fire probaction Systems, Names ambneent metal mare,And
mhwan�My be nexampary depending an Me opposed,orthe scoopful and Me water supply
Omer: PANERA BREAD#1781 SITE#: CALI-irl 326744
Overper'sAddress: 899ATLANTIC BOULEVARDATILANTIC BEACH.132233 Omer.Phone Number (9N)249-9358
Property Being Evalwated: PMERABREAD#1781
Property Address: 899 ATLANTIC BOULEVARD ATLANTIC BEACH,FL.32233
DateofPsork: 2018-04-02 AJI responses refer to the current wark(Inspection,testing and Maintenance)performseed on III clate.
This work is(check ol OMonthly 0 oughterly @Armual 0 Third Year 0 Fifth Year
Pan I-�oes Seaction
A Is Me Severe—1. 1 ONO 4,Annual Inspection Items(in mamn to above Inums)
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K Owner or hip.requensts WAFS to relearse information from D Visible pro manul manum be—red Fee ONO
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supply beasymay? Sypy oft OVA I ReNbeiverephimmum PsIaMR-" PSI
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and ads" (Ell.. ON. A,Man it..1. psi and FddmdmA
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va.mientiand.1.11housill Orr.. ONO OVA 8 Am Or sonvidem new moo or l�o 0...to deal. ...0yes ONO
C per napprem Numbers 20 an mom years No repposed
(I ONO OWA AshomandsmarrummuMvievers? Q)NSC Or" ONO
CALLII: 326744
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Oyes, ONO
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4 F~�hw�rdunngdmlnt@MWP�M��$%St�m
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sonsesessayunnesempoppeopil.asparnme
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wouphatent shaded ad the time was afted opeoppeoned oppi upon somparson Or as y i naposmon trends
a.parted an Pad 111..
mra suppay Or wor, pronompay,does not spent, w—OF Me sponamper or Me Olson system passed
Date: 2[1
Signature of intspenclor:
54P
Print Name: TAILSTOCK
Lisomed, r Certification Number(if applicable): FPI-170DD027
Color of tag placed on system: Which systems am Red Tagged:
F F r?
Red Yellow, Green
613 K.W.MERCANTILE PEACE 3226 CHERRY PALM DRIVE
PORT ST.LUCIE,FIL 34986 TAMPA,FIE 33619
772-878-330-FAX:772-878-5967 \"V"07A0MNE 813.630-0303-FA)E 81 3-6304312
11326 DISTRIBUTION AVENUE WEST 4683 LAREDO AVENUE
JACKSONVILLE,FLORIDA 32256-2745 A.tometic Fire Sprinklers, Inc. FORT MYERS,FLORIDA 33905
9�268-3030-FAX;9N.26"7U 222 CAPITOL CT. 239�3-3030-1":239433-3263
4370 MOTORSPORT DRIVE OCOEE, FL 34761-3033 3121 NW 16TH TERRACE
CONCORD,NORTH CAROLINA U027 407-656-3030-407-656-8026 POMPANO BEACH,FLORIDA 330U
7N.7824032-FAX:704-795-6838 951-917-3030-FAX:SU-9174424
Backfiow Prevention Assembly Test Report
CUSTOMER: PANERABREAD#1781 INSPECTOR: TAILSTOCK DATE: 2018-04-02
ADDRESS: SNATLANTICBOULEVAM LICENSEM T02-17-10120 TIME:
CITY,ST,ZIP: ATLANTIC BEACH,FIL,32233 ISC#:
JOBLOCATION: PANERABREAD#1781
ADDRESS: 899 ATLANTIC BOULEVARD ATLANTIC BEACH,FIE.32233
LOCATION(CHECK&DESCRIBE): C INSIDE G ABOVE GROUND r PIT USAGE(CHECK ONE): F-FIRE D? DOMESTIC
REAR HE CORNER OF STORE NEXT TO DUMPSTERS
(')DC r DOC r, DDC-BYPASS (*, RPZ C'RPZ-DET r RPZ-DET-BYPASS MFG MODEL E SERIAL#
TYPE(CHEC,0: WILKIN I 975XL S21.ZO FIII132
REDUCED PRESSURE PRINCIPLE ASSEMBLY (q-, YES DATE
RELIEF PORTS ON RPZ FREE OF CONTINOUS DISCHARGE?(CHECK ONE) (7 NO INSTALLED
APPARENT PME.SSUR.E DROP
A.Ro��"P� E. DAM
DOUBLE CHECK VALVE ASSEMBLY REBUILT
CHECK VALVE#1 CHECK VALVE 02 RELIEF VALVE PVB1SVB
HELDAT PSID HELDAT 1.4 PSID OPENED AT 2.0 PSID AIR INLET
- OPENED AT PSID
4 LEAKED LEAKED DID NOT OPEN
r DID NOT OPEN F
E CLOSED TIGHT CLOSED TIGHT
CLEANED CLEANED CLEANED CLEANED r
REPLACED REPLACED REPLACED REPLACED
PSID PSID AIR INLET PSID
PSID
a CLOSED TIGHT CLOSED TIGHT I CHECK VALVE PSID
(0)PASS 0 FAIL SUPPLY PRESSURE
METERM
READING#:
BFPINSERVICE
IN
CERTIFICATION TAG ON BFP FSPECTOWSSI NATURE:
613 N.W.MERCANTILE PLACE 3226 CHERRY PALM DRIVE
PORT ST.LUCIE,FL U906 TAMPA,FL 3MI9
77247843M-FAX:772478-5967 \VAVM�AYNE 01 3.63D.0303-FAX:81 3-630-0312
11326 DISTRIBUTION AVENUE WEST 4683 LAREDO AVENUE
JACKSONVILLE,FLORIDA 32256-2145 Autoinstic Fkv SprWiiirst. bc. FORT MYERS,FLORIDA 33906
9M.268-3030-FAX:904-20-0724 222 CAPITOL CT. 239433-3030-FAX:239433-3263
4370 MOTORSPORT DRIVE OCOEE, FL 34761-3033 3121 NIN ISTH TERRACE
CONCORD,NORTH CAROLINA 20027 407-656-3030-407-656-8026 POMPANO BEACH.FLORIDA 33N4
704-7824032�I":7N-796�838 9541-917-3030-FAX:SM-917-9424
Backflow Prevention Assembly Test Report
CUSTOMER: PANERABREAD#1781 INSPECTOR: TAILSTOCK
ADDRESS: 899ATLANTIC BOULEVARD LICENSE#: T02-17-10120
CITY,ST,ZIP: ATLANTIC BEACH,FL.32233 3ZI17"
JOBLOCATION: PANERA BREAD#1781
ADDRESS: 899 ATLANTIC BOULEVARD ATLANTIC BEACH,FL.U233
LOCATION(CHECK&DESCRIBE): C.' INSIDE (t' ABOVE GROUND (' PIT USAGE(CHECK ONE): FIRE OZ DOMESTIC
REAR NE CORNER OF STORE NEXT TO DUMPSTERS
CDC (- DOC (, DDC-BYPASS re,RPZ (,RPZ.DET (,RPZ-DET-BYPASS MFG MODEL BIZE SERIAL#
TYPE(CHECK): WILKIN I 975XL 1.0 3939885
REDUCED PRESSURE PRINCIPLE ASSEMBLY re, YES DATE
RELIEF PORTS ON RPZ FREE OF CONTINOUS DISCHARGE?(CHECK ONE) (- NO INSTALLED
PRE E�P
��ME�IRV E=V&� REBUILT
DOUBLE CHECK VALVE ASSEMBLY DATE
CHECK VALVE 91 CHECK VALVE 02 REUEF VALVE PVBISVB
HELD AT 8.0 PSID HELD AT 2.6 PSID OPENED AT 2.0 PSID AIR INLET
- OPENED AT PSI-
LEAKED LEAKED DID NOT OPEN F
DID NOT OPEN
z CLOSED TIGHT CLOSED TIGHT
CLEANED CLEANED CLEANED CLEANED F
Q REPLACED F REPLACED REPLACED F REPLACED F
PSID _PSID AIRINUET_ PSID
PSID
CHECKVALVE PSID
CLOSED TIGHT CLOSED TIGHT
re,PASS C)FAIL SUPPLY PRESSURE
METERM
READINGN
BFP IN SERVICE
CERTIFICATION TAG ON BFP F��I NATURE: �WAZ;z'-- I
613 N.W.MERCANTILE PLACE 3226 CHERRY PALM DRIVE
PORT ST.LUCIE,FIL 34996 TAMPA,FIL 33619
7724784350-FAX:772-87M967 \"V'51mMYNE 8134304303-FAX:813.630-0312
11326 DISTRIBUTION AVENUE WEST 4683 LAREDO AVENUE
JACKSONVILLE,FLORIDA 32256-2745 Automatic Fire Sprinklers, Inc. FORT MYERS,FLORIDA 33905
9W268-3030-FAX;904-2684724 222 CAPITOL CT. 239433-3030-FAX:239433-3263
4370 MOTORSPORT DRIVE OCOEE, FL 34761-3033 3121 NW ISTH TERRACE
CONCORD,NORTH CAROLINA 28027 407-656-3030-407-656-8026 POMPANO BEACH,FLORIDA 330U
7N.7824032-FAX:7W79548M 9�917-3030-FAX:964-917-94U
Backflow Prevention Assembly Test Report
CUSTOMER: PANERABREAD#1781 INSPECTOR: TAILSTOCK DATE: 2018��2
ADDRESS: 899 ATLANTIC BOULEVARD LICENSE* T02-17-10120 TIME:
CITY,ST,ZIP: ATLAN nC BEACH.FL.32233 Ise# 3267�
JOBLOCATION: PANERABREAD#1781
ADDRESS: 899ATLANTIC BOULEVARDATLANTIC BEACH.FL.32233
LOCATION(CHECK&DESCRIBE): (- INSIDE (a, ABOVEGROUND IF PIT USAGE(CHECK ONE): OZ FIRE r- DOMESTIC
REAR NE CORNER OF STORE NEXT TO DUMPSTERS
(-�)DC (,�DOG (P DDC-SYPASS r, RPZ (7 RPZ-DET ( ,RPZ-DET-BYPASS MFG MODEL SIZE SERIAL0
TYPE(CHECK): WILIKINI 950XL .750 1 3890282
REDUCED PRESSURE PRINCIPLE ASSEMBLY C, YES DATE
RELIEF PORTS ON RPZ FREE OF CONTINOUS DISCHARGE?(CHECK ONE) (-; NO INSTALLED
�PAR WPRES=DwP
VALVE ASSEMBLY �"RST. VAL� DATE
DOUBLE CHECK I I REBUILT
CHECK VALVE#1 CHECK VALVE#2 REUEFVALVE PVfffsVB
HELD AT 2.8 PSID HELD AT 2.4 PSID OPENEDAT PSID AIR INLET
OPENEDAT PSID
LEAKED LEAKED r DIONOTOPEN r
CLOSECTIGHT CLOSED TIGHT R DID NOT OPEN F
CLEANED CLEANED r CLEANED CLEANED r-
r- F F
REPLACED REPLACED REPLACED REPLACED
PSID PSID AIR INLET PSID
PSID
CLOSED TIGHT CLOSED TIGHT F- CHECKVALVE PSID
ro,PASS 0,FAIL SUPPLY PRESSURE
METER#;
READING#:
BFPINSERVICE
CERTIFICATION TAG ON BFP �WSPCTOR.SSI NATURE:
613 N.W.MERCANTILE PLACE 3226 CHERRY PALM DRIVE
PORT ST.LUCIE,FIL U986 TAMPA,FIL 33619
71247843M-FAX:772-8784967 \"V* WOMYNE 8134130-0303-FAX:81 3 4304312
11326 DISTPJBUTION AVENUE WEST Automatic Fire Sprinklers. Inc. 4683 LAREDO AVENUE
JACKSONVILLE.FLORIDA 32256-2746 FORT MYERS,FLORIDA 33905
904-2684030-FAX:904-2604724 222 CAPITOL CT. 239433-3030-FAX:239433-3263
4370 MOTORSPORT DRIVE OCOEE, FL 34761-3033 3121 NW 16TH TERRACE
CONCORD,NORTH CAROLINA 28027 407-656-3030-407-656-8026 POMPANO BEACH,FLORIDA 330"
704-782-3032-FAX:704-795-6838 954-917-3030.FAX:9�911-94U
Backflow Prevention Assembly Test Report
CUSTOMER: PANERABRFAD#1781 INSPECTOR TAJLSTOCK DATE*=2111-1"2,,
TI
ADDRESS: 8%ATLANTIC BOULEVARD LICENSE 0: T02-17-10120 TIME:
CITY,ST,ZIP: ATLANTIC BEACH,FL.32233 ISC#: 326744
JOBLOCATION: PANERABREAD#1781
ADDRESS: 899 ATLANTIC BOULEVARD ATLANTIC BEACH.FL.32233
LOCATION(CHECK&DESCRIBE): (- INSIDE Q! ABOVE GROUND r PIT USAGE(CHECK ONE): OZ FIRE DOMESTIC
REAR NE CORNER OF STORE NE)(TTO DUMPSTERS
C',DO Ie DOC (-, DDC-BYPASS r RPZ r,RPZ-DET (' RPZ-DET-BYPASS MFG MODEL SIZE SERIAL#
TYPE(CHI WILKIN I 350ADA 6.0 V39892
REDUCED PRESSURE PRINCIPLE ASSEMBLY C YES DATE
RELIEF PORTS ON RPZ FREE OF CONTINOUS DISCHARGE?(CHECK ONE) (- NO INSTALLED
I ArP-E-'RT..-URE.-I DAM
DOUBLE CHECK VALVE ASSEMBLY �S'R. �.Kv�� I REBUILT
CHECK VALVE 91 CHECK VALVE#2 RELIEF VALVE PVB/SVB
HELD AT 3.8 PSID HELD AT 2.4 PSID OPENED AT PSID AIR INLET
OPENEDAT PSO
LEAKED LEAKED r DID NOT OPEN F
DID NOT OPEN
CLOSED TIGHT CLOSED TIGHT
CLEANED CLEANED CLEANED CLEANED
REPLACED REPLACED REPLACED REPLACED
PSID PSID AIR INLET PSID
PSID
CLOSED TIGHT CLOSED TIGH1 CHECKVALVE PSID
PASS C FAIL SUPPLY PRESSURE
METER#:
REAdDINCIP.
CERTIFICATION TAG ON BFP NATURE; BFPINSERVICE
613 INK MERCANTILE PLACE 3226 CHERRY PALM DRIVE
TAMPA,FL 33619
PORT ST.LUCIE,FIL U986
772-878�3350-FAX:772-078-5967 813430-0303-FAX:81 3 4304312
113H DISTRIBUTION AVENUE WEST ""AWMYNIE 4683"REDO AVENUE
JACKSONVILLE,FLORIDA 32256-2745 Autmunatic Fire Sprinklers, Inc. FORT MYERS,FLORIDA 33905
904-268.3DW-FAX:904-2611-0724 222 CAPITOL CT. 239433�030-FAX:239433-3263
4370 MOTORSPORT DRIVE 3121 NVY 16M TERRACE
OCOEE,FL 34761-3033 POMPANO BEACH,FLORIDA 33064
CONCORD,NORTH CAROLINA 28027 407-666-3030-407-656-8026 964-917-3030-FAX:9541-917-94Z4
71�182-3032-FAX:704-79540138
Fire Alarm System Inspection and Testing Report
-ttils testing was performed in accordance Win applicable N.F.P.A.standards.
ONtner: PANERA BREAD#1781 ISC st 326744 Date 2018-�02
O�.Address: 8%ATLANTIC BOULEVARD ATLANTIC BEACH,FL.32233
Property Being Einaluated: PANERA BREAD#1781
Property Address: 899 ATLANTIC BOULEVARD ATLANTIC BEACH.FL.S2233
Monitoring Entity Panel Manufactuner: FIRE LITE Model No. MS-gMUD
Name: CONSOLIDATED FIRE CircuitStyles: STYLE B(CLASS B)STYLE Y(CLASS N) And l(SLC)1(NAC)
Telephone: (800)662-1711 Last Date System Had Service Peribnmed: UNK
Account Ref.No. A21-54M Last Date Solteeare or Configuration Was REARead: V13 B2 I OCTOBER 2013
Servica, All i An BCH DIR OF PUBLIC SAFETY
Weekly
Monthly AHJ phone# (904)247-6864
Quartedy (�' -Digital
Senni-Annually (*7 -R.F.
Other Specify
Other(Spereft)
Inspected by(pdnt) TAILSTOCK Date: 20l&-0"2 Time
Signature ofAlann Agent: (Agent Mesets Requirement$Per Florida Statute 489.518)
Nam of Omtner or repmetuartati" Amanda
Signature Date: 2018-04-02
I�ld NO to have a�Of NIPPANTe I n O� ONO
Cramer or esp.rectitude,WAFS to release hifienrualon frome
inspections to the undenemitems Of MY Insurance company. OYOS ONO System restored to normal operabon:Tim:
Notifications are made Yes No Me Time
Monitoring Entity V r— —
Building Occupants 15Z F-
Building Management
Other Specify)
1. ALARM NOTIFICATION APPLIANCES TEST AND INSPECTION
Device Cieit Style/Quarafty Operational Test Approired Location Pas. Fall
Bell. Quantity( I Size( 6 Type(Ac v r—
Home A( B( I- F-
Speakers A( B( F- F- r-
Chimes A� S( I r- F- r-
Strobes A( S( F- r- F-
Other.(Specify) A( I Big v R F-
HORNSTROSE No.ofluarmIndicatingetrouits: 1 AmCir.ufts,erwmadl? (,—Y.. (—No
Page 2
11,INIT10111413 AND SUPERVISORY DEVICE TEST AND INSPEC TION ass Fail
Device - Chwit StylaiQuentity, - Operational Test - Simulated Test P
Manuel Stations A B( 3 1 F
Ion Detectors A B( I r—
Photo Detectors A B( I I F
Dud Detectors A B( I F
Heat Detective A I B( I F
Waterhad Detectors A B( I I F
Supervisory Switches A I B( 3 I F-
Pressure Swit.1-ras A I B I I F F F
Lovi,Air A I B I I F
Other(spect A I B( I
Ill. SUPERVISORY SIGNAL INITIATING DEVICES&CIRCUIT INFORMATION
SifteWaterTernia. C Yes C,No (is NIA
Site Water Level (-Yes No (9)NIA
Fire Pump POviar r Yes No WA
Fire Pump Running ryes (7 No r*WA
Fire Pump Auto Position C Yes rNo N/A
Fire Pump or Pump Control Trouble Yes No Ill
Generator In Auto PoSition Yes No rl�'WA
Gewrator or Centralist Trouble Yes r;No N/A
SWtch Transfer Yes ONO NIA
Generator Engine Running Yes ( ,No NIA
Lock Box (,Yes r.No N/A
A.SIGNALING LINE CIRCUITS
Quantity and style(Be.NFPA 72,Table 3-6)0 signaling line CHWH5 connected to system
Quantity I Style(S)� 4
IV.SYSTEM POWER SUPPLIES
A.Pahmary(Main):Normal Voltage 120 Amiss 3
OvercarmudProuschon:Type: BREAKER Amps 20
Locationfidarvelli (PANELIGP)
Disconnecting Mean Location: #29
B.Secondary(Standby): 24V
ShmageBaftery:Ani Rating 7AH
Calculated capacity to opera rs: DZ 24 r so
Na Engine driven generator dedicated to fire alanand System:
C.Location of Fuel Storage! No
D.TYPE BATTERY SECONDARY POWER
Type Visual F,mrWral
Dry Cell Battery Condition VZ
Nickel Cadmium Load Voltage Pass
Seated Lead-Acid Discharge Test Min
Offner Basely): Specific Gravity F
E.Emergency or standby system used as a back-up to primary pomr supply,instead of using a ascondary
covas'SUPply. NO Emergency system described In NTPA...Article 700.
Page 3
V.SYSTEM TESTS&INSPECTIONS
A.Type Visual Functional D.Notification Appliances Valued Functional
Cormcl Pawl 0z Audible V F
Interface Equipment r Visual
..E.D�III Lamps 9 Speakers
Fuses/MicrOlInaakem F Voice Clancy
Prinsm,P�r Supply
Trouble Signals
Disconnect Switches
Ground Fault Monitoring E.ON I OFF pmorwass Monitoring
Y. No NIA
B.Emergency Cosmnunk-Umn Equipment Namn Signal ro (7
Type Visual Functional NIA Ala.Restonal rw
Phone Set F Trouble Signal (0-1
Plume Jacks Trouble Reshral R, C
Off Hook Indicators Supervisory Signal re
Amptifier(s) Su,pervisory Restoral la`�,
Tom Gerserator(s) Reasons Anuciator
Call In signal
System Performance
C.broarlace Equipment DEVICE SIMULATED
(SPECIFY) VISUAL OPERATION OPERATION
F
r r-
Special Hatard System(Specify) F
r
V1.COMMENTS:
Mi.DEFICIENCIES: Mass items are Me O."s weposequilly to be repalmardand"I be quoted SePAr8ta ftmo Inspection cost
Trouble on panel upon arrival ground fault