INSTALLING COMPANY
Address:
City:
Phone:
Company Certificate of Registration Number
PROTECTED PROPERTY SYSTEM INFORMATION
Name:
System Manufacturer's Name:
Street Address: Installation Manual: UL Number: Date:
City: Zip: Design type: Pre-engineered: Engineered:
Owner or Owner's representative instructed on system operation & maintenance: Yes No
If Pre-engineered, Model Number
Owners Rep, if applicable: Coverage Type: Total Flooding: Local App:
LOCAL AUTHORITY HAVING JURISDICTION System Actuation: Automatic: Manual:
Name: Air/Fan shutdown on actuation?Yes: No:
Street Address: Design discharge rate or concentration level:
City: Zip: Design discharge time: Seconds:
HAZARD ANALYSIS AGENT INFORMATION
Name of area, room, building or hazard protected
Qty Storage cylinder Manufacturer Part No. Amount of agent
Primary Class of Protected Hazard
Class A - Wood, paper, etc. Class D - Combustible metals
Class B - Flammable liquids Explosives EQUIPMENT INFORMATION
Class C - Electrical equipment Initiating Devices
Qty Item Manufacturer Part No. Temperature
Kitchen Hoods & Appliance System
Fusible Links
Height Length Width Is hazard normally occupied? Sprinkler Heads
Overall Hood ft x ft x ft Yes No N/A Heat Detectors
Plenum ft x ft Size of Hazard Smoke Detectors
Exhaust duct perimeter in Total Volume cuft Other Fire Detectors
Appliances Gas or or Total Area sqft Manual Pull Stations
Qty Protected Elect Length Width Height Length Width Nozzles Part No. Qty Part No.
Deep Fat Fryer in x in approx. ft x ft x ft
Range in x in approx. ft x ft x ft
Griddle in x in approx. ft x ft x ft
Char Broiler in x in Area sealed to prevent agent loss? Interlock Item Manufacturer Part No.
Radiant Broiler in x in Yes No N/A Fan or A/C Shutdown
Upright Broiler in x in Number of room air changes per Gas line Shut-off
in x in minute? /min. N/A Electric Shut-off
in x in Warning & instruction signs posted? TESTING
in x in Yes No N/A Method system was tested:
This system was installed in accordance I certify that this fixed fire extinguishing system has been tested and complies with the Reproduce Form & Distribute
with the following codes: requirements of Chapter 6001 of the Texas Insurance Code, as amended, and the fire Original to Protected Premise
NFPA Year
extinguisher rules and adopted NFPA Standards.
Copy 1 to Installing Contractor
NFPA Year
Copy 2 Certifying Firm for
Year Planning Superintendent & License Number for access by SFMO
Year Signature of Licensee & License Number Completion Date
back of the
form, or
additional
paper, to
sketch the
piping
configuratio
n and
click to sign
signature
click to edit
![]()
