Ventless Submittal Information

APPLICATION FOR EXEMPTION FROM MECHANICAL VENTILATION
1. Applicant Name(s):____________________________________________ Telephone: _______________________
Applicant Name(s):____________________________________________ Telephone: _______________________
2. Facility Name: _________________________________________________________________________________
Facility Address: _______________________________________________________________________________
3. Facility Type: Restaurant ____ Market ______ Bakery _______ Other ____________________________
4. Appliance Type (rotisserie, oven, etc.): ______________________________________ Weight: __________
5. Equipment Manufacturer: ________________________________________________________________________
Address: ___________________________________________________
______
____________________________
Model: ________________________________________________ Specifications Included? Yes ____ No ____
6. Heat Source: Electric ____ Gas ____ Solid (wood, charcoal, etc.) ____ Microwave ____
Other (specify): ________________________________________________________________________________
7. Certified to meet NSF/ANSI Standard 4? Yes _____ No _____ Don’t Know ______
If “yes”, certifying organization: NSF Int’l ____ ETL/I _____ UL Sanitation (EPH) _____
Other certifying organization (specify): _______________________________________________________
8. Hours per day of operation of appliance: ___________ Number of days/week: _____
9. Approximate size of facility (square feet): _______________Of area/room with cooking equipment______________
10. Area/Room ceiling height______________ Ventilation (CFM )
in r
oom/area_____________________
11. # of appliances currently in use that have been previously approved for use without mechanical ventilation: _______
12. How many appliances are you requesting to install without mechanical exhaust ventilation? _________
13. Types of foods to be cooked in the appliance (check all that apply):
a. Pre-cooked wrapped/packaged foods-reheat only: _____
b. Baked goods: (including bread, rolls, pastries, pies, cookies, cakes, etc.): ________
c. Vegetables: (including baked potatoes, steamed vegetables, beans, etc.): ________
d. Pizza: ____ frozen par baked: ______ made fresh: ______
e. Sandwiches: (containing only ready to eat fillings): ______
f. Raw meats and/or raw eggs: (meat, fish, poultry): _______
g. Open cooking: (sauté, grill, etc.): ______
h. Deep fat fried foods: ____
______
i.
Other (specify): __________________________________________________________
14. “Ductless” ventilation provided: Yes ______ No _______
If yes, is it included with appliance? _______ or installed separately? _________
► Ductless Hood Manufacturer: _________________________ Model: _______________
► Complies with UL Standard 197? Yes ____ No ____ Don’t know ______
________________________________________ ______________________________
APPLICANT SIGNATURE DATE
FOR OFFICE USE ONLY
Recd by ________________ Date ___________________ Amt. Recd ______________ Check # ______________
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