76 LAFAYETTE ST - BUILDING INSPECTION (10) � i .
r�
�'
4
�\
/ ��, 'Y The Commonweatth of Massachusetts �
. �J��i �� I� � Deparlment of Public Safefy
�j �` '�,',,.f \fa>s.ichu.alL+:+l.�le l3uildin};Code t:80 C�IR)`+eernlh EdiUun
City of Salem
Buildin Permit A lication for an Bui�din other than 1- r a ii Dwellin
1This Srctiim F��r l�f(icial Use Onlv)
� duddinti Prrmit 4umL+rr: Date AFiplied: S� � �1 �� Building InsFiect :
. SECTION 1: LOCATION IPlease inditate 81ock N and Lat M for locations for which a s re t address is not availablel
�� �f�.v,ette Sfrce-F ��.lew� 4�\A . af9�d
,V�i..indtitrre� Cih� iTu�rn��OZ ZipQide N,imeulBuildin�;lif,ipf�lic.�ble)
SEC710N 2: PROPOSFD WORK
II Nrw Cunstruceiun check hem O ur check all thal apply in Ihe twu rows beluw
Esisting Building Rrpair❑ Alteration Addition O Demolitiun O (Please fill out and submit ApNrndix 1) . _ .,�,a.
. Chingeuf Use ❑ Changeof Occupancy ❑ Other Sprcify:�oH�ercic.l (Cr�el.� � ��Cnl-.cnvST
Are building plans and/ur cunstructiun ducuments beinq�upplied.is par[of this permit applicatiun? Yes No ❑
Is an Independent Structural Enginrering Peer Review rcquired? Yes ❑ Nu ❑
. BrieF D�+cripti��n u1 Prup�ue�Wurk: 'r"visi'w�l ar 1 i� �c'-w�e'HC`'Ci c.� �C'?Ci^eh �ie�-UJ3T
�s'Fcw� �"�� MRLe -�IJ o.�^ c��.�?. f��rt�cre.-1�`c F�^�e 5�bn�es.�ib�1�e�n
i _..
SECTION 3:COMPCETE THIS SFCTION IF EXISTING BUILDING UNDERGOING REIVOVATiON,ADDIT[ON,OR
, CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is endosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): �'
Existing Hazard [ndex 780 CMR 34: Proposed Hazard Index 780 CMR 34: -
SECTION 4:BUIGDING HEIGHT AND AREA �
Existing Proposed
Nu.uf Fluors/Stories(include basement levels)&Area Per Floor(s9. ft.)
Tutal Area(sq.ft.)and Tutal Height(ft.)
SECfION 5:USE GROUP ICheck ae ap licable) �
� � A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
- F: Facto F-1 O F2 O H: Hi h Hazard H-1 ❑ H-2❑ H3 ❑ H-4❑ H-5❑
L• Instltutional i-1 O Id ❑ I-3� I-�❑ M: Mercantite❑ R: Residential R-1❑ R-2 ❑ R-3❑ R-4❑
S: Stnrage 41 ❑ S-2 ❑ U: Utility❑ Special Use�and please describe below:
4peCial Use: �
SECTION 6:CONSTRUCTiON IYPE(Check as a pliwble) �
� IA ❑ IO ❑ IIA ❑ 118 ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SF("TION 7:SITE INFORMA"f10N Irefer to i80 C�IR 711.0 for details on each item)
I LVafer Supply: i Flood Zone Inforniation: Sewage Disposal: Trench Pertnit: Uebris Remo�al:
PubLc � C heck �1 nul.ide 19n��d /_unr❑ hxii�a�e muninp,�l ❑ :\ lrcnch wtl ut he Lio�nwd Ui.po.al�ite
� rcywrcd �rtrcnch ur.prci(��:
IPrn�ete❑ ��rindvnt�icZ�rne:_. nrnn .ile.��.irm ❑ F.ermit �.cndu.rd ❑
� Raiimad righbof-wav: Hazards to Air.Vavigation: �I:\ I li.t��n� c'.,���i��i..�„u Rr�.i,�.� Pn,�r..:
� \��i \ h.�ibl��� !.}tru:�urc����hin au rt�i • •ri�.�di,vr.i.' I. Ihcir rc�ic�c rnin dctci�'
� P4' I �F" F F/ 4
• ,�r l�„n.rnt �n Ii�nIJ rnili�.vd ❑ 1 r.� nr \n f� l�c•. ❑ \�� ❑
� SECiION d:IONTENT OF CERTIFICA�E OP OCCUPAi�lCY
: I.Ji�i,�n „I � .1i _'_'_ l�at;n�uF��.r . fi��c,ii l���n.lru.�iun: __ t)ccuF,.ui� L��dJ F�cr I�lunr _"___
� Ih��. �Pirbuil�hn�;a�nldin.inti�.nn:.lor?�.Ivm'�. _ ?f�rci,il?tiFulatiun.� ..'_ ' ' I
c�'v/J ��f' ��r (.0� �� .�i'KL�.�lT"
I
' SECTION 9: PROPERIY OWNER AUTHORIZATION
N,�,(nr.tnd Ad. e�s�rl Prupeth'Otvner
� ��Q• c� (LC r2o �.1��„��it�n Sfi 5u;�< �2{� Se,le� f^�1lt. G(976
V.ime(PnnU Nu..ind titrcrt Cil��/i���.,n Lip
PrAnperl�'U�cnir Contart In���nn.itiun: p���
1'T�`Q`( SC'1nV�\;n �D�.(oZ,�-�,1tv-- _ —
Ti��i Trlrphone Vu. l�usmrssl TrlephunrNi�. (crll) r-m.ul.iddre�>
, if applic.iblr, thr Fuupe iv uwn�r hrrrbv auth��nze�
c,c S- c a l�2es 7��T��, S. CG���Se �. /��R aZ1J O
V.ime titn�rt Address Citv/T�nvn St.ite Zip
tu.�rt �m thr ,ni,rrtc���aner'.brholl, m all m.�tten rvlativr lu wurk.iuthur¢rd bv this buildin � �ermrt a , ,licatiun.
SECTION t0:CONSTRUCTION CONTROL IPlease till out Appendix 2)
lll buildin•ie Ivs:th�n i9,lAlOui.fL o1 rnaloKd s+a:e and/or n.rt undcr Qmstruetion Cunlrol Ihen check herc O and ski+Sceliun 10.1)
10.1 Re istered Professional Res onsible for Construction Control
�Qi.�re�ce �a,� /� � 7�L-Z4�-S�F�- 1.a�SaLvf�CoR'P.Cbnn 3VSoS
Name(Rrgistrint) Telephone N e-mi�l address Registratiun Number
�F �,��1,a c�- � r�p�'.plc�, � ofg�o Mc�.�+ F.c�
Strcet Addres� City/Town titate Zip Discipline Bxpimtiun Date
103 General Contractor
�ci/�nn,�rJ �2as
Co piny Name: �
,1�,�fc �e r ncnrt�l CS 7Z�'�9 �
Namr u(Person Respon.ib�e(or Constnii[iun - License No. and Type if Applicable
7c' Si�h S'�. Cl,.e�se� � o21J'�
Street Address City/Town - State Zip
'�S {- SIIO __ �IPICK(aSEfarv�ANi3RoS . CcM
Tele hone No.(business) Tele hone No.(cell) - e-mail address
SECTTON 11:WORKERS'CO.'bII'ENSATION INSURANCE AFFIDAVIT(M.G.L.c.152. 25C(6)) '
� A Workers'Cumpen�ation Insurance Affidavit from the MA Department of Industrial Acciden must be completed and
submitted with this applica[ion. Failure to provide this affidavit will resul[in the denial of the' uance of the building permit.
. Is a si ned Affidavit submitted with thisa lication7 Yes Na ❑ ��
SECTION 12:CONS'IRUCTION COSTS AND PERMIT FEE ��
I[em Estima[ed Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ .
l. Building $ ( 7S0' Building Permit Pee=Total Construction Cost x_pnsert here
2. Etectrical 5 appropriate mun�ipal factor)_$ .
3. P�umbing 8 �i
4. Mechanical (HVAq g Note:�Minimum fee=$�(rontact municipality)
$. Mechanical (Other) S Hncluse check i ible to � �
P�Y�
G.T�rtal Cost S (contact munici ality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPL(CANT
. Bv entenn�my name beluw, I herebv,�tte.t under the painsand penaities uf perjury that all uf the in(urmatiun cnntained in Ihis �.
.iF,plicaliun is trirc,md accur.�Z!n th�best ol mv knowlydy;e ind undervt�indin�;. �
��. S-noN,a I �l,aJ( ! �� , M. Cnf� -��I . 81C0 � o
19c.�.rpnni ,�nd.ihnn.ur .' �idr rrlcphuneXii. i)alc '.
� zc- cxr+� S�. C�•21sr� ry �r ,
I ?h'rct .lditrc.. C itt';�Tu�cn Idt G E� �
i '
U
� � >1uni.ipal Inspectur ro fill out this srction upon application approval: _ ! ( � �'� �
. \'.i e I)ete �
� '
� i �2�� I
2 D � t �
�
,
�
.
�; 2s sacn st.
' � � BROS. INC. Chelsea, MA 02150 Sales Order Number S06913
_ USA Sales Order Date: Apr 23, 2010
s„Mrs��.d..r:�,�,nt��,�„�n��,m,�.c Shi B A r23, 2010
n..t;,m.r���n,t„n;,�,.si,�r«,�r<„r„���fK;��d,2nr.ea,�,,,,,,s:�,,,�„�.� Voice: 617-884-8110 P Y� P
` Page: 1
n,,,�„��s,��mi�,...r���ar„o,���,;,,,� Fax: 617-884-4284
�e FH �t" t C'.S 3�` `� Eif fi '�A � , k ` x'£, �A 9ry t i
�lio: .� � ,`�,�;�'�',�, ° ��rss'��"!�'�.�� �{� ,.,. � SF�iprTn��g:? s�;,�'�� ' a r €?�"a� ���'�1���``;`'���,�',��
.v�`r ,�+ i 3.� "'�w ,�s_c. , x.��.a.,��'`:".�..i��. �S.di,�n i u,.rs �w ?.�:� a t
Howling WofF Howling Wolf
76 Lafayette Street 76 Lafayette Street
Sa�em, MA 01970 Salem, MA 01970
Voice 617-778-1521
Fax 617-778-1505
e .
;§A �� ° ='��C stOmef�ID �� �fi ����u �_ rn r�s� PQ Numbet� ' �, <<.. s � $alesrl�ep Nam'e*�k��i,'_s� �
,
'� �.�t.il a `. _ �
�.. _ �- _
.�a w._,.�e_ r��,s_ � -- c� ,�e .,<< _�t.�,, . ,�. . .�
Taco Place Jack Seidman
� , �`' �Cus�omer�Con"tact '�,� �� ' � 4�C �;Shipp�ng,Methotl �y;, �'����� PaymentTerms��� �.�����
N
,n. m _.�, � M, ,�.� ,. . ..�,o.._ ... a,...,R _
Patrick Schuitr Our Truck C.O.D. �
�, �- x. i?a -z--�r�-�n {„ i ' � i� g. ia�n ra",, g,' -r�F�;= .
�,��uQuantrtY� + _ .... ;,. Item��;"" ��. ", �. .�-� .��;?�-.PQScciptwnr.s�;t.�4 �`r�wu'���UnitPnce��.���.-Amount,�! ��)
,.. a . . ..: . � __ . a � ,
11.00 se makeuphood Stainless Steel Rear Discharge Make-up air Hood 285.00 3,135.00 �
with Baffle Filters and removable Grease cup. Priced '
by the foot. � '
11.00 se ssrdpnl Stainless Steel wall panels mounted on wall under 45.00 495.00 �
rear discharge, by the foot. II
2.00 p 24h Hood light fixture complete with Globe. Mounting hole 45.00 90.00 I
� cut into the hood.
1.00 se exsys Exhaust System with 20", 1HP, 2 speed, 120v. 4,950.00 4,950.00
upblast Fan, hinged wall curb, and welded 19"Duct.
Ductto run thru hallway and storage room
walls and terminate on exterior wall. Duct will have
two cleanouts installed on the side of the duct in
� accessible positions.4400 CFM @ 1925 FPM
114.00 infab 999 Single layer of Zero Clearence Duct Wrap, by the 9.50 1,083.00
square Foot, to cover the duct from the first wall
penetration to the exterior wall.
1.00 se musys Make-up air System with 15" 1HP, 2 speed, 120v, 3,950.00 3,950.00
Blower Fan,with a Filtered Housing,wall curb, and
Ductwork. 3960 CFM = 90% '
returned to room. Duct to run to same exterior wall,
10'from exhaust.
1.00 Job-Fire UL-300 Fire suppression system to coverthe hood 2,750.00 2,750.00 I
i
Subtotal Continued
Sales Tax Co�n nue
Freight Confinued
TOTAL°ORDER`AMOUNT' '� �s�'M`; �����, ��-��'" �"'�ConY�riueds,
i. .3�. ,.:�+« 'xacuMvvi > '1::`. w l.�,t. . , r. . '�SS4slh4i+FnP;ircfiN.��e
Finance Charae is computed at 2% monthlV (z4°/a APR) on all
balances over 30 days old.
' ! 191, � 25 Sixth St.
' _ � , i � BR05. INC. USAsea, MA 02150 Sales Order Number: S06913
I
Sales Order Date: Apr 23, 2010
f,.,�.as<.,�,,,s�n6„���,��u���e.c Shi B A r23, 2010
n�m�n�r�;n,�.�,�,v,�,.sli,�„��r,���,,,��Kr�m.,�c�a��,�,�sy,a�.,,�, Voice: 817-884-8110 P Y� P
c<,.,,�„�,s,�,nae.ucsr,.�r�,��.r�„���,� Fax: 617-884-4284 Page: . 2
�;�,,x''e ,^� 3*�,e;. ,�a G'. {' r '�'i m �, � '. i 'f`�F -x n � s'� z� t�`� z �.r�"t n.�. kt 3 3
7Qi� s ,. ,y��'s��rx ��� t,�'s�,i�41�'��".;��a;.{rs�.��.�k��.'>��`�$�s,�„r ��.n`i: Shipr#TO`�`,k�.,�t" ., ?. s_.x:'(u f �`.� -;-'�.�5�:-',', ";�.�, �2..., �..a�, � ,.f . ,—���I
a:
Howling Wolf Howling Wolf il
76 Lafayette Street 76 Lafayette Street
Salem, MA 01970 Salem, MA 01970
Voice .617-778-1521 I
IFax 617-778-1505 �
,,��'_" Y���'�CpstomerlD � w� ;��������s,��sj��s� PONumber�"'�°a '�`"��;����'��`��`� �,`a��v�`'��'��SalesRep«Name���'��;"-€�',,�tl
ri. �,
��� . :� �,�. �.. _.. . u... ._ . ,. ,.. �
Taco Place Jack Seidman '
�,� ��Custonl�r�Co,rStaat��'� �} , �n� y ;�,js�Shipp�ng;Method, "'� ,, „ ��F ��. �; „ ,`�Payment�Terms� ` � a:� �_
3. . . , �,�;�..�s
Patrick Schul� Our Truck C.O.D.
,�a,���Q�anttty'; � �� -�,�Item � � ��,;�. � � ����Descript�on���'; re'��++��^ e^*ry rUnitPriceGo��+, �� �sAmount��n� ,i.
> . . ...., , ....�, .�. � � . . �r S,�`,:t ��.a,�, u .�, �at .� � � ; r :�
__.�.__—
duct and Iisted appliances under the hood. (VaNe to !�
be installed by customers plumber NIC) �
Job-engdrw Stamped engineered drawing of the exhaust system 750.00 i
for the Building Dept. (If required by the town) '
Job-Prmt cnsit Consulting with Inspectional Services in your town. 550.00 ;
InGudes permitfee. j
1.00 Job-Custom Extend Exhaust and Supplyduct 16'forvvard to side 1,200.00 1,200.00 �
wall in dining room.
�
� Price includes delivery and setup of listed equipment. ;
Unless specified, NO plumbing, electrical, carpentry, il
or subcontraded work is included in this price. SBI
will hammer through the brick wall and support the '
penetrations with steel channel. Codng would not be �
induded.
Fire suppression system will be supplied with both the I�,
mechanical gas vabe and an electric solenoid valve i
with the manual rest switch up to 1Y"dia. Larger
I
sizes would incur an upgraded price. Anything not
listed is not induded. '�,
�
�
Subtotal 17,653.0�
Sales Tax ����
Freight 0.00 !,
TOTAL40RDERAMOUNT ,. 4 �n � � ����;� ��`�� w '���`�_ -�%�"`��'�8 75� 31,''�
_ � �`� �;�.. � �-d�:��,�.�r ��� �,�r�sx=—
Finance Charqe is computed at 2% monthiv (24% APR) on all
balances over 30 days old.
�
� � l..-�. 37 �ss.�cliusMTa- De�urimen't oP Pu7ilrc.�i�t'ct�
q Mia.u�tt���f 6uil4i�r� Rc„ulatiti�is irid ��nnllarAs .
- � } �e-_ �. Consfructian Supervisar l�cense .
�
� License: GS 72179 " �
� ts w.'y, rS,92 � ,
°
�C511'iC�Hfl LO Q� � � '1 � (
a 4�
.. �� dACKP 5EI'DMAN � '�� ��� ; I,�
� 25 SIXTH ST ��� �
� �� CHELSEA,,MA 02150 - �
i � �-L _-d.,-:�r,.� Expirafion: it/?J2011 .,
(.niili�iskianw�. Trk: 9216
-. _. ...._ ._.. .
. _.....................
_............._...
I
r �
�
�
� :
t ,
May 7, 2010 Dodge Area LLC
C/O RCG LLC
'17 Ivaloo Street
Patfick SChUIz Somenrille, MA 02143
76 Lafayette St#102 120 Washington Stree4, Suite 202A
Salem, MA 01970 Salem, MA 01970
� T8176258395 �
F&17 625 8345
Dear Pat, www.RCG-LLC.cnm
In reference to the plans submitted to the Landtord and our subsequent correspondence today, piease I�
accept this letter as documentad permission f�om the Landtord to install the Hood and Vent associated
equipment as depicted in the submitted drawing and as discussed in person. This permissfon is
contingent upon the submittal and approval of any applicable locai goveming boards, more specifically,
but not limited to, Salem Fire Prevention and the Salem �esign Review Board.
Regard
- - AlexandetSch i - -
On Behalf of Dodge Area LLC �
1
� .,�� The Commonwealth ofMassachusetts
Department of Industrial Accidents
• Office oflnvestigations
� ' 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: BuilderslContractors/Electricians/Plumbers
Applicant Information Please Print Le�ibiv
�T8TT1C (Business/Organization/Individual): �[(j��q� ��Q,pS �� C�
Address: S �x-t� S�' • li
City/State/Zip:Ci,:�1s ey 6� c4 . 0 2 i �� Phone #: � 17 ^�$ � ' � t I d
A�re,�y an employer? Check the appropriate box: Typ¢of project(required): �
1.� I am a em lo er with � � 4. � I am a general contractor and I
P Y �— 6. ❑New construction il
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ;
ship and have no employees These sub-contractors have g. � Demolition
, working for me in any capacity. employees and have workers' 9. ❑ Building addition
�No workers' comp. insurance comp. insurance.i
required.] 5. � We aze a corporation and its 10.0 Electrical repairs or additions i
3.❑ 1 am a homeowner doing all work officers have exercised their 11.Q Plumbing repairs or additions I
myself. [No workers' comp. right of exemption per MGL 12.0 R of repairs �
insurance required.] t c. 152, §1(4), and we have no I
employees. [No workers' 13. Other�x�.wr.it' S�s�'z`^�
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below sliowing their workers'compensation policy information.
t Homeowners who submit this af£davit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
;ConVactors that check[his box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. �
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: �a��t�1�� �t—�nS Cd � —
Policy# or Self-ins. Lic. #: � C y��F57C � Expiration Date: 3/3T
JobSiteAddress: "�� �a-��',.etie ��. City/State/Zip: S�lev� M� p(`��C�
Attach a copy of the workers' compensation policy dedaration page (showing the policy number and expiratiou date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certif�y under the nins an�l penalties ofperjury that the information provided above is true and correet.
� /
SiQnature• �/� Date• S��/7//C)
Phone#� v �n f� — gg`{ ' R� � 0
Official use only. Do not write in Uiis area, to be completed by ciry or town official.
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
404/05/2010 10:05 6173892418 S PAGE 01
��� CERTIFICATE OF LIABIL,ITY INSURANCE ppIp LY DATE�M0.90Uivrih
SEIDM 1 04 05
.muo�re THIS C RTIFI ATE I 1 ED AS A R OF NFORMATION
, ONLY AND CONFERS NO RIGHT9 UPON THE CBRTIFICATE
Sanviti Iaeurance HOLDER,THIS CERTIFICATfi DOES NOT AMEND,BXTEND OR
699 Breadway ALT6RTHECOVERAGEAFFORDEDBYTHEPOI,IGE9BELOW.
EvereCt l� 02149 -
Phoae: 617-389^2�20 Fax:617-389-a^418 INSURER8APFORDIN�COVERAG@ NAIC#
M9URED �` INSURERN: A8TS0y9V31�.Q 2ns Co. �, 35696
INSURER B:
9 j. A HLOtF1B�C3 IN$URER G _
�2 7L%'Eh 3tt9Bb INBURERD: '�
e aea D� 02150 ' I
IN9UNEIY E: �
covEaac�s
THE POUGE9 0F INSUMNCE LIBTEU BELONI HAVfi BEEN IS&UEq TO TH5 MSUA6�NMAE�A90NE FOR THE POLICV PERI00 INpICATEO.NOTNITHSTANDING ii
ANY REOUIREMENT�TERM OR CONDITION OC qNY COMMCT OR OTNE0.DOOUMENT WITH REBP@GT TO WM�CN TWIS CERTIPICATE MAY BE�93UED OR '
MAY P6RTNN,TNE INSURANCEAPFORUED 9YTME P06�C�RS A9SCF�9E0 NEFEIN IS 5U9JHCT TO�LLTMETERMB.EXOLUBIONS PND CONDRION6 OF 6UCX
POLICIBF�406P2G����MRS SNOWN MAY MAVE 90EN REOUGEb BY PAIO CLAIM6, ,,,,,,r.r
L SR TYPBOFMB RANC6 POLIOYNUMBER � A7L MIUD IJMIT6
6ENE7tAL LIAB�U7V EACH OCCURRBNa4 0 7,000000
GE'TQREIOTE[T--
H R COMM6RC�ALGENENN.LIn�IIiTY 98P68831D �9��.$��9 09/15/10 PRfiMI �F_8_�Eamurteroe a300000
CWIM3MADE X❑ OCCUR , MEGEJ(PIAnYa�aaa�^1 B 5000
aeasonwtanovmauRr x1000000
OENERAI.ACORfiQAT5 92000000
GEN'lA6GRE0AT8LIMITAPPLIB6P8R; PftObVC7B-CAMPIOPA00 WaO0O000 _�^
� POLIOY JRC lOG
` AUTOM061LELIA6ILITY COMBMEDBINOLQIIMIT
A r�uvauro BAB@198D 10/OB/09 10/08/10 «"°'•'aam� �1000000
ALL OWN6D AUT08 BODILV INJl1�iY
$ SCHEOULE�AUT09 (Pneparoen) �
R MIR@DnUTOS BOOILYINJURY
][ NONA'NN6DA1JT04 (FneneaideM) g
PROPER'iYD�GF. a1000000
(Per nmldantl
I GARA6EW61LIT' AUTOONLV•EAACCI�6M' 6 �
Aryyh�7p YHEqTHp N QAACC 3
RUTO ONI,V; AG6 6
O(OE89/UM79RELIALVi91L1iV SACHOCCURR6NC6 @
OCGUR � CtAIM6MA�@ AGGREGn7E 8
8
OEpUC'�81,6 S
RETENTION r A
EN ri0N . - � - — - NRY LIMI E
An0 EMPLOVERS'LIABILITY
H oFFice°��aexcLuoo�Ecunvr�j W�aMg765 03/31/10 03/31/11 E.l EA0MA0CIDENT s 100000
IMenanieyinnln) �—� E.L.DIBENBE•EAEMPLOYc s100000
IPym tlesalbewidur .
9PQ�IALPROVISIONS�IIow E.I.DIBEN32-POIfOTLIMIT 6$0����
OTMPR
OE3CRIVTION OF OPBFl�710N3�LOCAAONS f VEMICLES I E%CLU510 6 ADDED 9V ENOORBEMENT/SPBCIAL PROVISION9
CERTIFICATE HOLDER CANC6LLATION
BMOULD ANY OF THE ABOV@ DESCI116ED PpUC�BS 9E OANO6LLED BEFORE THE EfIPIRAiION
, CATETHEREOF,TH5199UINGIN9URERNnLLENDEAVONTOMNL 3� OAYBWRIttEN
� NOTICE TO TM8 CERiIFICATE HOLO@R NAMEO TO TNE LFPT�BUT FAIW RE TO DO SO SNAIL
� IMP0.9E w0 Oe�lon7ioN OR uae�Lm oP aNY KIND UPON 7H61N9Up�,rtS acer+7s pR
pEPRE9ENTATNE6.
AYTHORIZED RE7RfiSENTA .
,w, .
ACORb 25(2009l0'I) � ` �' At ON, Alf rlghta raserved.
TNe ACORD name end logo ara registerad marks p4 ACOR
' � ,
11' H00 3" AIR SPACER •
12" FLEXIBLE
oucrs, rvP. EQUIPMENT SCHEDULE � �
� �
6" MAKE ZERO CLEARANCE � `�
Exhaust Hood #1 -Stainiess steel Rear Discharge 18 � G� �
UP AIR DUCT WRAP ga. hood, 11'X 48'X 24"hfgh, full length filter � � �
_  radc, all welded grease shell, removable grease L� �
_ ,�, cup,6"supply plenum on rear, UL List� Baflie � �
_ qg° 19°x19" DUCT i' FlltersandLlghtFixtures. �
g EF-1 - 20"Upblast Exhaust Fan, with 1 HP, 120 V,two � � q
� � speed motor, hinged curb. 4400 CFM @ 1925 r� � �
� � FPM in an 19'X 19�weld�l 16 ga. bladc iron o �, �c
_ = duct. Q � �2
MU-1 - Non tempered Make-up air System with 15", 1 � � �
HP, 1204 Blower Fan in a filtered hou�ng. 3960 �j � �
CFM = 90% retumed to room. �
10' MIN. Flre Suppresslon - UL-300 fire suppr�sion system will �
be installed to cover the hoods,ducts,and
appliances under the hood.
Note:
1. Upon activation of the Fire Suppression System, � �
22"x22' DUCT MU-1 � �
the Exhaust fan shall remain on,and the supply I o
system,gas feed, and any electriml outlets under ', �� N
Me protected area shall�ut down. ^ z -
2. The exhaust ducts are to be wrapped with zero I I � o
dearance duct wrap within 18"of combustfbles =
and on horizontal run through bullding. � �
3. System is bulit to meet NFPA%and ali local � ¢ �
PLAlV V 1� tlI w\ m � �
building codes. � r� ',� w Q
Q z�
U � Q
ES �i
4
� O
w �, ,,.
�,_ „
NON—COMBUSTIBLE 10' MIN. � �
12" FLEXIBLE WALL
DUCT, 11'P. M -1 EF-1
O C� �ia�i�i�ui��nn i�mi� �i�ui�oi� � �
24"
PULL STATION
LOCATED AT UL LISTED �'
EGRESS BAFFLE w
FILTERS —8' MIN. w
AND 6'-6"
°O °° °° LIGHT � �
UL 300 FIRE � a• U ��
SUPPRESSION SYSTEM I FIXTURES � �
�
CftIDDLE CHRRBROILER SI%BUPNER �EEP � O � O
AUTOMATIC GAS caiu awcc ra+ca
SHUTDOWN VALVE
I z � � �
FRONT ELEVATION SIDE ELEVATION EXTERIOR ELEVATION � � � W
o a
J o
� o � � �
� �
, -
�,
� 11' H00 3" AIR SPACER "
12" FLEXIBLE
oucTs, rrP. EQUIPMENT SCHEDULE � �, �
6" MAKE ZERO CLEARANCE
UP AIR DUCT WRAP �aust Hood #1 - Stainiess steel Rear Disdiarge 18 �i �p
ga. hood, il'X 48"X 24'high, full lengti�filter � � �
_ _ radc, all weld�grease shell, rercrovable grease � �
= r, cup, 6"supply plenum on rear, UL Listed Bafiie � �
= q �� 19"x19" DUCT i Filtersand LigM Wctures. �
� EFi - 20"Upblast Exhaust Fan, with 1 HP, 120 V,two � � �
� � FP� ��9'X 9�eld�l 1�6 ga black 9ron o � �
— — dud. Q � �
MU-1 - Non tempered Make-up air System with 15", 1 � � �
HP, 1204 Blower Fan In a filtered housing. 3%0 � � �
CFM = 90% returned to room. �
10' MIN. Fire Suppresslon - UL-300 Fire suppression system wlll �
be Instalied to cover the haods,ducts,and
appltances und�the hood.
Note:
22"x22° DUCT MU-1 1. Upon activatlon of the Flre Suppresslan System, � o
the Exhaust fan shall remain on,and the supply � o
/ system, gas feed, and any electiml oWets under ' r� N
the protected area shall shut down. � z _
2. The exhaust ducts are to be wrapped with zero I I � o
clearance duct wrap within 18"of wmbusdbles =
and on horizontal run through bullding. � —'
PLAN VIE�Y 3. System is bullt W meet NFPA%and all local w� m � �
building oodes. Q r� z � � ¢
U � Q
' � �
tT �
>
��
� � .�
� � I
NON-COMBUSTIBLE 10' MIN. '� g �f" � I,
12° FLEXIBLE WALL �
DUCT, TYP. M -1 EF-1
O O �iu�uuuiu�i�u i��oi� �uuuuu � _ �
24"
PULL STATION
LOCATED AT UL LISTED �
EGRESS BAFFLE w
FILTERS -8' MIN. �
AND 6,_6° �'H"° �
°O °° °o LIGHT
U� 300 FIRE � a• FIXTURES �� ��
SUPPRESSION SYSTEM � � d�
� � .-�
CRIpDtE CiW2BP01LER 9%BUPNER DEEP O � O
AUTOMATIC GAS `a"` """" `"""
SHUTDOWN VALVE
z � � �
� � d �
FRONT ELEVATION SIDE ELEVATION EXTERIOR, ELEVATION o � ,.� w
J �
� mo r`7"-e � U�
�