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APPLIGATION FOR PERMIT
City or Town:
Date:
Yarmouth
05 /L5 /20L2
Permit Number: 101062
ln accordance with the provisions of M.G.L. Chapter 148, as provided in Section 10 A application is hereby made
by:
Address
For permission to: lnstall Fire Alarm System (COMiTERCIAL)527CMR10:03
Name of Competent Operator:ccA BiI Cert.
Date lssued-Rejected OS / L5/2OL2
Date of Expiration: 08 lLS / 2OL2
By
137
HANKO,I
Fee: 100 . 00 $ paid
(SEnature of applicant)
Due
,llrrl
/South Yarmouth, MA 02664
CAPE COD INSULATION
18 REARDON CIRCLE, SOUTH YARMOUTH
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h his Protec.tion System including materiatand labo
with ahore sprcifications, forthe sum ol:
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r'rve isiche te bewiU cgrea
Due 0pon Completion.
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APPLICATION FOR PERMIT
YARMOUTH
MAY 10,2012
ln accordance with the provisions of M.G.L. Chapter 148, as provided in Section
by Cape Cod Alarm Co.. Inc.
FP6 (r€v. 3/00)
City or Town
Date
(Ful nane ol ,€,rson, Fim ot Coaoaton)
Address 204 Old Townhouse Road West Yarmouth, MA,02673
(St.eet or P.O Aox) (City or Town)
INSTALL FIRE COMMERCIALFor permission to (state clearly purpose for which permit is requested)
FIRE SYSTEM @I8 REARDON CIRCLE, CAPE COD INSULATION
Name of competent operator (lf Applicable)CAPE COD ALARM COMPANY 6"x. 11s. 1592C
Oate lssued-rejected By
(Sign ature of Appticant )
Date of expiration Fee $100.00 $Paid Due_4
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PERMIT
FP6 (rev. 3/00)
City or Town
Permit Number (if applicable)
ln accordance with the provisions of M.G.L. Chapter 148, as provided in
to
this permit is granted
DIG SAFE NUMBER
Start Date
(Ful name of pe.son, Fim ot Coryoralion)
for
Restrictions
at
(Give locaion by street and no,, ot clascribe in such hennar as to pmvida adequale identilicalion ol localion)
Fee Paid $This Permit will expire on
Signature of Official Granting Permit_ Title
N f}rir permit must be conspicuously posted upon the premises f
application is hereby made
noto
,"{sz"Fire Sprinklar Specialist
TYPE MAXE MODEL
15087470992
TEST OUTLET'
SEC
AI-ARI{
OPERATED
PROPERLYYES NO
p.2
CONTRACTORS ilATERTAL A TEST CERTIF|CATE FOR A BoI'EGROUND PlPIilG
MIN
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I
II
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ffi5,:ffi , ,"", irEpcdirg and rltt ,r.r E m.d. t, rh. Eddrcrors ,.9re5.dci,e rd riit'rscr, Dv L 6fpfE '"0*rerrariu.
^i o.e* a,.:, U. "-rt"a .nd sryElstl lslt h !e'ric! bGbI€ F sotT l f'tl' b 'e
the iob'
thlll be lilbd .rn.nd sir.d by borh lepr.a6 rt..s- cotie! sh.ll bc areFrd fo..pF.olring .ttho,tirs' ow€,!. aod co'f'clor- lt k
the crnEls rw"!en[.tr've'B 6iltat e in rE w'y prqudas ahy dsin agai]6 coitrsdor br bulty m6tsri'l' poot vtotkrBnrhb' 6 teilure
or local qdirglces-
c6ftifcate
DATE
PRO PERTY NAME
PROPERTY ADDRESS
O l{otrNo.w esrcceprto pums
INS-r ALIATION CO}fORMS TO
IF NO.E(PLAIN DEVIATIONS
tr Yes
EOUIPIEI{T USED IS APPROVED
PLANS
IF NO. EXPLAIN
Yes B NoLOCATION
VALVES
ASDB,ISTRUCTEBEENNCHARGEASH
OF EOUIPIVENT?NEWMAINTEiI/{NCEANDCAREAl.ro
1. SYSTEM COMPOI'ENTS INSTRI'CTIONS
2. CARE AhID MAINIENANCE INSTRUCTIONS
D Yes
E YesE Yes
trNotrNotrNo
lHE FOLLO'IiING EEEN LEFT ON THE PREMISES;coPrEs oF
3 NFPAzs
i[iTRUCTION
supprrs gutLDtNG:LOCAIION
OF SYSTE ORFICE
SIZE
TA'PERATURE
RATING
YEAR tr
MANIJFACTTFiE QUAI{TTTYMODELi,t KE
SPRIN
12 afd
-Scttd.oF Fipe:T}?e
ot FinirEsrCast
PIPE AND
FIYTI]iIGS
TIGU TEST OONNECTION
MMIMUM TllrE TO OPERATE
AJqRtvl OEVICEAI-ARIII
VALVE
oR Fr-ow
INDICATOR o.o.D.DRT VALVE
SERIAL NOMOOETMAKESERIAL NO.lvl0DELMAKE-.
AIR
PSIPStPSr
TIME TO TRIP
THRU TEST \MTER AIR
TI
MIN
WITH O,O D,
NO, EXPLAIN:
DRY PIPE
OPERATING
TEST
II
aa
3'GD
II
@ E
-
I I
-
EfrTfl
rIN EEIEEI
ilffi
-
iuusuneo rRou rtME lNsPEcroRs TEST CONNECTION OPENEO
MIN
(ovER)
lrlh
TOEOUIruENIFIREOFPERSON
THECONTROL
,rg.52a Fire Sprinkler Specialist 15087470992 p.3
rtoN
HYDRA,JI.ICPN EUMATI EI.ECTRIC
NoDDETECTING LiEDlA SIJPERTnS E YPINGD Yes trNo
TRIP ANUOR REMOTE CONTROL STADOES VALVE OPERATE
CIRCUIT FOR TESTII{G EXPLAINIS THERE AN ACCESSTBTE FACILITY IN
EYes fl No
UM TIIYG TO
RELEASERELEASE?
DOES
SEN LOSS AIARM?
OPEFATE
MODELMAKE
TEST
DESGSPTION
(10.2 !.c)tor arc tEtrs. of.rr .! dy+pc yJe! d.rp.r! rhd b htt oFr drdn, trtb Prllr.nl &l'.!.- Al .bo,egro6d P'piI l..l(!ga shtl ba 3bpPc
PNELlrATte E,t.IirI aO l.(27 b:rE) .ir Fiss.rE.rn m€ uE dlp riic|l 3i.l not atrc.!.d t-1r2 psl (0.1 BB) lfl 2rr ior.5. T.3l P.!..ur€ a.rlr..t
b.r.) c!or,!.t lic F6!l. id-'t-3 ol lS0tbdro3Llia l!6E sndl bc midc d noi lcss t anaia Fd1!.6Et.)t r'!o lElls o, 50
Et6l -d .ir prr&grt ao!, ftrtr€ .ir ,ltch ddl lDtcx..d 1-112 !61 (o.l Eirt) in 2a lllni.
lF Nq STATE REASON:ALL PIPING HYDROSTATICALLY TESTEO AT
DRyptprNG pNEuMATtcaLy TESTED ,,4 D Yes tr l,b
g4tLPSTFOR _8_rns
EAUIPMENT OPERATES PROPERLY El Yes
oo YoU CERTIFY As
'IIE
SPRII0(LER coNTRAcIoR .THAT ADOrIT,/ES AXO C(RROSNE CIIEMICALS. SOOUT'I SIrcATE G DERIVATIVES OF
SODIUM SITJCA'IE, 8RI}E, OR OTHER CORROSTE CHEi CALS WERE I'IOT IJSED FOR TESNIG S'STEMS OR STOM'{G LEAKS'
El Yes ENo
RESIDUAL PRESS1JRE WITH VALVE IN TEST
colttEcTroN opEN wDE 6 ?. pst
fernoruc or orc: uocaro
lcor.,rccnon ED NEAR WATER SUPPLY TEST
PSI
IEST
.IESTS
UNoERGRoUiID xAN ANO IEAO III C€M{ECIOrls TO STSIEM RISERS FLUSHED EETORE CONXESIIO{ I.IADE TO SPRNXI.IB PIPING
VERTFTED By coPy Fo rHE u FoRM r.lo. ssB E Yes E No
FLITSHED By INsTALIER oF UNDER- tr Yes El No
GROUND SPRINKLER APING
OTTER EXPLAIN
Nt ll,lBER REMOVEDNL'VIBER USED LOCATIONSBI-ANK
IESTlt{G
GASKEfS
WELDiNG
----.,]
THE SPRINKLER CONTRACTOR THAT WELUNG PROCED.JRES COf,IPLY
CONTROL PROCEDI.,RE TO INSI'IRE TIIAT AL DISCS ARE RETRIB/ED, TTTAT
IN PIPNG ARE ST,OOTH, T}IAT SLAG AI\D OIIiER V'/ELOING RESIDUE ARE REMCI\,/ED, AND fHAT
E Yes
tr No
No
ING PIPING
I
DO YOU
AWS DIO.g, LEVEL AR.3?THE REQUIREM
DO YOU CERTIFY THAT THE
E YesPLIANCEIREMENTS OF AT LEAST A\A'S D0.9.
FY TI.IAT VVELDING WAS CARRIEO OUT IN @MPI-IANCE WTH AYcr.,
INTERNAL BIAIIIE]ERS OF PIPING ARE NOT PENETRATED?E Y€s
Yes [f No
CUTOUTS
(Drscs)
Do YcxJ cERnFY T}6T YoU HAVE A CONTRoI- FEATURE TO ENSURE THAT ALL
c]'rTcnlTs (uscS) ARE RETRIEVED?O Yes tr No
HYDRAUUC
DATE
NAUEPIATE
NAIT1E PI.ATE PROVIDEO
$Yes El No
IF NO, EXPLAIN
REMARXS DATE I..EFT IN SERVICE WITH ALL MNTROL VALVE OPEN:
NA'{E OF SPRINKLER CO+JTRACTOR F,t< se;^,*/ez o-. , -. /;s-/
(srGNED)OR TnLE
s(
SIGNATURES
./' IADorloNAL o(pl NATrdl-{Ho ruores I-
ET Ef,ltrElilrrll:rffiil
-*T
DELUGE &
PREAGTIOI{
VALVES
-
DNo
OUALIFIED IN