HomeMy WebLinkAboutBuilding Permit #Exception - 1600 OSGOOD STREET 5/1/2018 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received
Date Issued:
IMPORTANT:Applicant must complete all items on this page 11
S v d .
' LOCATION:
--I "
PROPERTYrQWNER C( ,S 1Pnnt'( t,(S � cohJ - _- _..
Paint? 100 Yeap0ld Structure . yes', no
MAP'N0PARCEL-:._- ZONIN&DISTRICT' HistoricrDistricV yes- no
Machme:Shop Village, yes no;
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
0 New Building ❑ One family
11Addition 11Two or more family ❑ Industrial
0 Alteration No. of units: ❑ Commercial
0 Repair, replacement 0 Assessory Bldg PF Others:
❑ Demolition ❑ Other
'SepticVV'11 ❑fibodplain; aWetlands 0�Watershed District; .
E Water/Sewet.
DESCRIPTION OF WORK TO BE PERFORMED:
j4pnfification P_le se ype or Print Clearly) -/r?3
OWNER: Name: Phone: (O
Address:
Phone:.
CONTRACTOR, Name:
Address: ..
Supervisors Construction License Exp: Date:
!Home-ImprovemehtL'icense; Exp. Dater
ARCHITECT/ENGINEER Phone:
i
Address: Reg. No.
FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $
' Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
+ U ature of contractor
Signature of AgenJOwner
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/MassageMody Art ❑ .. .Swimming Pools ❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH ' Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Wa$er & Sewer Connection/Signa4ure Date Driveway Permit
DPW Tow ]Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTilf ENT - Temp Dumpster on site yes no
Located at'124 MainStreet
Fire Deparitmerit signature/elate
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A-F and G min.$100-$1000 fine
NOTES and DATA— (For department use
0 Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofil,g, Siding, Interior Rehabilitation Permits
o Building Permit Application
❑ Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
❑ Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
o Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
a Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
o Engineering Affidavits for Engineered products
NIOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
o Building Permit Application
Li Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
a Copy of Contract
❑ Mass check Energy Compliance Report
o Engineering Affidavits for Engineered products
gOTE: All dumpster permits require sign offrom Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm;tted with the building application
Doc: Doc.Building permit Revised 2012
Commonwealth of Massachusetts
Department of Public Safety (DPS)
Amusement Device Inspection Checklist
Section I shall be completed by the Amusement Company
Owner or > /I i Device Location ,ry Date of Inspection ! l r
Company Name " S i� ' ' f.! 1.r,
}
f- Serial Number DPS Company 7 '
Name of Device „t License No. /!!
Manufacturers
Maximum Device USID Is this first inspection?
! / ! -., , r
Speed(RPM) Number / �� r 11V Yes i o
r
Section 2 shall be completed first by the Certified Maintenance Mechanic(CMM)following a thorough review of the device,then by the DPS
inspector. The CMM and DPS inspector shall indicate with a checkmark ✓if the item is satisfactory;with an X if unsatisfactory or
that the item does not apply(NA).
CMM DPS Inspection Checklist Items. CMM DPS Inspection Checklist Items.
Maintenance Records for the last 30 days , Signal systems,and control devices,including
1 including the daily maintenance logs. emergency stops and overspeed systems.
Daily operator's log. 12 Device structure and visible moving parts.
Operator training records and operator / 13 Blocking and leveling systems.
3 identification. - V
4 Manufacturer's Data Plate and USID Plate. Jr 14 Proper bracing,anchors and guy lines.
5 Safety belts,bars,locks and other passenger r 15 Adjacent hazards and interferences.
restraining devices.
6 Automatic and manual safety devices, 16 Guarding on motors,sprockets,chains,rails,belts
' including safety lockout switches. ,l' V and drives.
7 Fencing,guards,barricades,stairways and 1 Brakes,hydraulic,pneumatic or mechanical,perm,
L' ramps. y 'r magnet.
V 8 Visible bolting,safety pins and keys. r 1 g Hydraulics and air systems,generator,generator
' grounded.
}: 9 Observed device in operation. •` L 19 Containment and seat numbers.
10
Signage. 20 Manufacturer's Maintenance Checklist and manual.
Does the device require re-inspection by DPS or Third Party _ Yes No Re-inspected by: Date
Inspector? Check YES or NO and circle appropriate Inspector.
Comments below indicate items that require attention. Please check ✓ the appropriate box to indicate who made the comment;either Certified
Maintenance Mechanic(CMM)or DPS inspector(DPS). Also,check ✓ the Complete box once corrections are made.
CMM DPS Complete
CMM
CMM DPS
R
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
The DPS Commissioner or his/her designee may cause a device to be taken out of service and not allowed to operate.CMM Yes No
shall Indicate whether or not the device was allowed tooperate at the referenced location.
This Amusement Device has been inspected by the Certified Maintenance Mechanic(CMM)and DPS inspector to the best of his/her abilities in
accordance with 520 CMR 5.00. The CMM is responsible for correcting items herein identified prior to operating the device.
Print and Sign Name of .
fDateCMM. r.. I
.'k ./ 7.,".,r i � /,?^ /• ,r 5•/
Print Name of DPS
Inspector(s) _ ` f' 5 r , i � ) >,°t` i Date t; _o f.j � I
WHITE copy to DPS,CANARY copy to DPS inspector,PINK copy is retained by the Owner.
p:\anntsement device inspection checklist 2012 revised.docx
Commonwealth of Massachusetts r
Wf i�l Department of Public Safety (DPS)
Amusement Device Inspection Checklist
Section 1 shall be completed by the Amusement Company
Owner or / Device Location �j,' t Date of Inspection r
Company Name
Name of Devicer Serial Number DPS Company
License No.
Manufacturers Maximum Device USID Is this first inspection?
Speed(RPM) Number i ;
i lr �'l rS � , Yes No
Section 2 shall be completed first by the Certified Maintenance Mechanic(CMM)following a thorough review of the device,then by the DPS
inspector. The CMM and DPS inspector shall indicate with a checkmark ✓if the item is satisfactory;with an X if unsatisfactory or
that the item does not apply(NA).
CMM DPS Inspection Checklist Items. CMM DPS Inspection Checklist Items.
�' .�'•� 1 Maintenance Records for the last 30 days / 11 Signal systems,and control devices,including
including the daily maintenance logs. V emergency stops and overspeed systems.
1, Daily operator's log. Device structure and visible moving parts.
i, 2 v"` V 12
i w Operator training records and operator Blocking and leveling systems.
3 identification. - 13
4 Manufacturer's Data Plate and USID Plate. 14 Proper bracing,anchors and guy lines.
5 Safety belts,bars,locks and other passenger 15 Adjacent hazards and interferences.
1 f restraining devices. L�f i
Automatic and manual safety devices, Guarding on motors,sprockets,chains,rails,belts
6 including safety lockout switches. t- 16 and drives.
Fencing,guards,barricades,stairways and 1 Brakes,hydraulic,pneumatic or mechanical,perm,
ramps. Lf magnet.
8 Visible bolting,safety pins and keys. r 1 g Hydraulics and air systems,generator,generator
grounded.
} 9 Observed device in operation. 19 Containment and seat numbers.
v' 10 Signage. L - 20 Manufacturer's Maintenance Checklist and manual.
Does the device require re-inspection by DPS or Third Party Yes NO Re-inspected by: Date
Inspector? Check YES or NO and circle appropriate Inspector.
Comments below indicate items that require attention. Please check ✓the appropriate box to indicate who made the comment;either Certified
Maintenance Mechanic(CMM)or DPS inspector(DPS). Also,check ✓the Complete box once corrections are made.
CMM DPS,_ Complete
CMM DPS
CMM 1 /DPS
CMM 'DPS r
CMM DPS
CMM DPS
CMM :DPS
CMM DPS
The DPS Commissioner or his/her designee may cause a device to be taken out of service and not allowed to operate. CMM[__yes No
shall Indicate whether or not the device was allowed tooperate at the referenced location.
This Amusement Device has been,inspected by the Certified Maintenance Mechanic(CMM)and DPS inspector to the best of his/her abilities in
accordance with 520 CMR 5.00. The CMM is responsible for correcting,items herein identified prior to operating the device:
Print and Sign Name of �/ % ,f 11
CMM. Date C /. _ /: ..
�
Print Name of DPS -� ' ' r% / Ll Inspectors) f i > ' _ Date /l,/ , /,/
WHITE copy to DPS,CANARY copy to DPS inspector,PINK copy is retained by the Owner.
p:\amusement device inspection checklist 2012 revised.docx
Commonwealth of Massachusetts
Department of Public Safety (DPS)
sad' Amusement Device Inspection Checklist
c
Section 1 shall be completed by the Amusement Company
Owner or Device Location Date of Inspection
Company Name
Name of Device
Serial Number DPS Company
%�' •
License No.
Manufacturers / f r Maximum Device FU SID Is this first inspection?
L
;:;�f;i^pl 1 Speed(RPM) Number r� : ) ,`j Yes No
Section 2 shall be completed first by the Certified Maintenance Mechanic(CMM)following a thorough review of the device,then by the DPS
inspector. The CMM and DPS inspector shall indicate with a checkmark ✓if the item is satisfactory;with an X if unsatisfactory or
that the item does not apply(NA).
CMM DPS Inspection Checklist Items. CMM DPS Inspection Checklist Items.
Maintenance Records for the last 30 days / Signal systems,and control devices,including
including the daily maintenance logs. yr j/ 11 emergency stops and overspeed systems.
2 Daily operator's log. ✓ i,-" 12 Device structure and visible moving parts.
3 Operator training records and operator l + ! 13 Blocking and leveling systems.
t, identification. f/
Manufacturer's Data Plate and USID Plate. . Proper bracing,anchors and guy lines.
4 14
'l 5 Safety belts,bars,locks and other passenger / 15 Adjacent hazards and interferences.
restraining devices.
t 6 Automatic and manual safety devices, j t 7, 16 Guarding on motors,sprockets,chains,rails,belts
�• (! including safety lockout switches. 1� and drives.
/ Fencing,guards,barricades,stairways andi 17 Brakes,hydraulic,pneumatic or mechanical,perm,
V ramps. } "J�: magnet.
8 Visible bolting,safety pins and keys. 1 1�' 18 Hydraulics and air systems,generator,generator
f` grounded.
9 Observed device in operation. 1/,' �� 19 Containment and seat numbers.
10 Signage. ✓�`, f- 20 Manufacturer's Maintenance Checklist and manual.
Does the device require re-inspection by DPS or Third Party Yes No Re-inspected by: Date
Inspector? Check YES or NO and circle appropriate Inspector.
Comments below indicate items that require attention. Please check ✓the appropriate box to indicate who made the comment;either Certified
._ Maintenance Mechanic(CMM)or DPS inspector(DPS). Also,check ✓ the Complete bar once corrections are made.
CMM l DPS Complete
..1 %i'i,'� �, /- J, a r,r� .{ r�i.".r/ � i'��'� �J'�,'�.•f1, Cff^�,/-�, .!{• 7 t
CMM DPS !
j � •�� r' 1r I •! '/f f I / ` 1 1 t`� f ,/ 1` �,'t�� �
CMM .r DPS'
CMM -DPS j - 711
CMM DPS '
CMM DPS
CMM DPS
CMM DPS
The DPS Commissioner or his/her designee may cause a device to be taken out of service and not allowed to operate.CMM Yes No
shall Indicate whether or not the device was allowed tooperate at the referenced location.
This Amusement Device has been inspected by the Certified Maintenance Mechanic(CMM)and DPS inspector to the best of his/her abilities in
accordance with 520 CMR 5.00. The CMM is responsible for correcting items herein identified prior to operating the device.,
Print and Sign Name of
CMM. 'r' .,�, ',- t r� i. Vit, !J , `!t t1/ Date
Print Name of DPSA
Inspector(s) .. ~�'` ( - - Date
Ins s
P ( ) �...1 r" � 19^-.1
WHITE copy to DPS,CANARY copy to DPS inspector,PINK copy is retained by the Owner.
p:\amusement device inspection checklist 2012 revised.docx
Commonwealth of Massachusetts
N h Department of Public Safety (DPS)
Amusement Device Inspection Checklist
c
Section 1 shall be completed by the Amusement Company ,
Owner or
Device Location Date of Inspection
/- JI)
,f�
Company Name { - ,'
t^ J Serial Number DPS Company 7
Name of Device ; }tJh If' License No.
Manufacturers ��// Maximum Device USID Is this first inspection?
Speed(RPM) Number �'.r)� �j �b' Yes ;No� t
Section 2 shall be completed first by the Certified Maintenance Mechanic(CMM)following a thorough review of the device,then by the DPS
inspector. The CMM and DPS inspector shall indicate with a checkmark ✓if the item is satisfactory;with an X if unsatisfactory or
that the item does not apply(NA).
CMM DPS Inspection Checklist Items. CMM DPS Inspection Checklist Items.
Maintenance Records for the last 30 daysSignal systems,and control devices,including
I including the daily maintenance logs. / U I I emergency stops and overspeed systems.
r` 2 Daily operator's log. t / 12 Device structure and visible moving parts.
3 Operator training records and operator 13 Blocking and leveling systems.
L identification. '
4 Manufacturer's Data Plate and USID Plate. 14 Proper bracing,anchors and guy lines.
f �.
5 Safety belts,bars,locks and other passenger / / 15 Adjacent hazards and interferences.
V restraining devices. Y ✓
r Automatic and manual safety devices, 1,' 16 Guarding on motors,sprockets,chains,rails,belts
6 including safety lockout switches. and drives.
Fencing,guards,barricades,stairways and ` F 17 Brakes,hydraulic,pneumatic or mechanical,perm,
f,!� 7 ramps. ` V magnet.
f Visible bolting,safety pins and keys. �' Hydraulics and air systems,generator,generator
g
% V L ►f 18 grounded.
9 Observed device in operation. 19 Containment and seat numbers.
r
V10 Signage. /,� 20 Manufacturer's Maintenance Checklist and manual.
Does the device require re-inspection by DPS or Third Party Yes No Re-inspected by: Date
Inspector? Check YES or NO and circle appropriate Inspector.
Comments below indicate items that require attention. Please check✓ the appropriate box to indicate who made the comment;either Certified
Maintenance Mechanic(CMM)or DPS inspector(DPS). Also,check ✓ the Complete box once corrections are made.
CMM DPS Complete
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
The DPS Commissioner or his/her designee may cause a device to betaken out of service and not allowed to operate. CMMI Yes I No
shall Indicate whether or not the device was allowed tooperate at the referenced location.
This Amusement Device has been inspected by the Certified Maintenance Mechanic(CMM)and DPS inspector to the best of his/her abilities in
accordance with 520 C4R 5.00. The CMM is responsible for correcting items herein identified prior to operating the device.
Print and Sign Name of / ' ' ' £ _/ i
Date l/ Z S
CMM.
Print Name of DPSf '
Inspector(s) -- - Date ,y A/ /1 -3
WHITE copy to DPS,CANARY copy to DPS inspector,PINK copy is retained by the Owner.
p:\amusement device inspection checklist 2012 revised.docx
Commonwealth of Massachusetts
Department of Public Safety (DPS)
Amusement Device Inspection Checklist
6SS"y�__w.�MO
Section 1 shall be completed by the Amusement Company
Owner or Device Location Date of Inspection f �'
Company Name
Name of Device Serial Number DPS Company '
License No.
Manufacturers Maximum Device USID Is this first inspection?
Speed(RPM) Number
-+;1'Hi Yes No 1
Section 2 shall be completed first by the Certified Maintenance Mechanic(CMM)following a thorough review of the device,then by the DPS
inspector. The CMM and DPS inspector shall indicate with a checkmark ✓if the item is satisfactory;with an X if unsatisfactory or
that the item does not apply(NA).
CMM DPS Inspection Checklist Items. CMM DPS Inspection Checklist Items.
Maintenance Records for the last 30 days f �� Signal systems,and control devices,including
1 including the daily maintenance logs. 1 11 emergency stops and overspeed systems.
r
2 Daily operator's log. f' f 12 Device structure and visible moving parts.
�.
Operator training records and operator i 13 Blocking and leveling systems.
3
identification. �'
4 Manufacturer's Data Plate and USID Plate. 14 Proper bracing,anchors and guy lines.
V
/ Safety belts,bars,locks and other passenger , Adjacent hazards and interferences.
d� 5 restraining devices. t0 15
6 Automatic and manual safety devices, / 16 Guarding on motors,sprockets,chains,rails,belts
V t including safety lockout switches. L' :� and drives.
f Fencing,guards,barricades,stairways and f'!,� 1 Brakes,hydraulic,pneumatic or mechanical,perm,
ramps. . yf magnet.
g Visible bolting,safety pins and keys. P� 1 S Hydraulics and air systems,generator,generator
/. . / grounded.
r 9 Observed device in operation. 19 Containment and seat numbers.
10 Signage. ' `, 20 Manufacturer's Maintenance Checklist and manual.
Does the device require re-inspection by DPS or Third Party Yes No Re-inspected by: Date
Inspector? Check YES or NO and circle appropriate Inspector.
Comments below indicate items that require attention. Please check✓ the appropriate box to indicate who made the comment;either Certified
Maintenance Mechanic(CMM)or DPS inspector(DPS). Also,check ✓ the Complete box once corrections are made.
CMM DPS Complete
CMM DPS r i✓' .' L
1: ci= P`
CMM 1`DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
The DPS Commissioner or his/her designee may cause a device to be taken out of service and not allowed to operate.CMM Yes No
sball Indicate whether or not the device was allowed tooperate at the referenced location.
This Amusement Device has been inspected by the Certified Maintenance Mechanic(CMM)and DPS inspector to the best of his/her abilities in
accordance with 520,CMR 5.00. The CMM-is responsible for correcting items herein identified prior tooperating the device.
Print and Sign Name of f ` f j
- / 1 {. �' Date ff
CMM. .i�z lir' ,t.' t"1.f1, ? !._tea z
Print Name of DPS ' ''(` `
Inspector(s) �4 Date/S
WHITE copy to DPS,CANARY copy to DPS inspector,PINK copy is retained by the Owner. t
p:\amusement device inspection checklist 2012 revised.docx
?� f
t
�5.:...-_..:.sic , t t � � • , t ,
Commonwealth of Massachusetts
Ln' �AI Department of Public Safety(DPS)
Amusement Device Inspection Checklist
Section l shall be completed by the Amusement Company
Owner or Device Location , ' + Date of Inspection
Company Name f lit 1 1/ i+-t/ft .� f
. t'
Name of Device /r% Serial Number DPS Company ,
License No.
i
Manufacturers f Maximum Device USID t Is this first inspection?
`f r-4 Speed(RPM) Number Yes ,No
Section 2 shall be completed first by the Certified Maintenance Mechanic(CMM)following a thorough review of the device,then by the DPS
inspector. The CMM and DPS inspector shall indicate with a checkmark vlif the item is satisfactory; with an X if unsatisfactory or
that the item does not apply(NA).
CMM DPS Inspection Checklist Items. CMM DPS Inspection Checklist Items.
I Maintenance Records for the last 30 days ,t :1 Signal systems,and control devices,including
including the daily maintenance logs. /ii 1, f I I emergency stops and overspeed systems.
2 Daily operator's log. 12 Device structure and visible moving parts.
I f 3 Operator training records and operator G�, �/ 13 Blocking and leveling systems.
✓ identification.
V 4 Manufacturer's Data Plate and USID Plate. 14 Proper bracing,anchors and guy lines.
Safety belts,bars,locks and other passenger Adjacent hazards and interferences.
V i/ 5 restraining devices. 15
6 Automatic and manual safety devices, Guarding on motors,sprockets,chains,rails,belts
including safety lockout switches. I' 16 and drives.
7 Fencing,guards,barricades,stairways and t ,+ .' 17 Brakes,hydraulic,pneumatic or mechanical,perm,
t� ramps. / : magnet.
8 Visible bolting,safety pins and keys. 18 Hydraulics and air systems,generator,generator
r j grounded.
t/ 9 Observed device in operation. l� ,� 19 Containment and seat numbers.
V I 0 Signage. 1 L, 20 Manufacturer's Maintenance Checklist and manual.
Does the device require re-inspection by DPS or Third Party Yes No Re-inspected by: Date
Inspector? Check YES or NO and circle appropriate Inspector.
Comments below indicate items that require attention. Please check v/the appropriate box to indicate who made the comment;either Certified
Maintenance Mechanic(CMM)or DPS inspector(DPS). Also,check Y/ the Complete box once corrections are made.
CMM DPS Complete
CMM DPS - //7
.1 y
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS 1, ,
CMM DPS
The DPS Commissioner or his/her designee may cause a device to be taken out of service and not allowed to operate. CMM Yes No
shall Indicate whether or not the device was allowed tooperate at the referenced location.
This Amusement Device has been inspected by the Certified Maintenance Mechanic(CMM)and DPS inspector to the best of his/her abilities in
accordance with 520 CMR 5.00. The CMM is responsible for correcting items herein identified prior to operating the device.
Print and Sign Name of /
CMM. %(. 4 t,,�} 1��L .t �r . , , Date
Print Name of DPS
Inspector(s) ,1.' .� - - Date
WHITE copy to DPS,CANARY copy to DPS inspector,PINK copy is retained by the Owner.
p:\amusement device inspection checklist 2012 revised.docx
Commonwealth of Massachusetts
Department of Public Safety (DPS)
LAI
Amusement Device Inspection Checklist
Section 1 shall be completed by the Amusement Company
Owner or Device Location i Date of Inspection
Company Name - !�, ; I� '.� ?
Serial Number DPS Company
Name of Device
` ?/,?_10.#_. License No.
Manufacturers Maximum Device USID Is this first inspection?
!, Speed(RPM) Number Yes l/No
t:°t �( 7
c ,
Section 2 shall be completed first by the Certified Maintenance Mechanic(CMM)following a thorough review of the device,then by the DPS
inspector. The CMM and DPS inspector shall indicate with a checkmark ✓if the item is satisfactory;with an X if unsatisfactory or
that the item does not apply(NA).
CMM DPS Inspection Checklist Items. CMM DPS Inspection Checklist Items.
Maintenance Records for the last 30 days Signal systems,and control devices,including
G 1 including the daily maintenance logs. c 11 emergency stops and overspeed systems.
l
2 Daily operator's log. 12 Device structure and visible moving parts.
I✓-
Operator training records and operator / , I 13 Blocking and leveling systems.
G% d 3 identification. L/
`• �' 4 Manufacturer's Data Plate and USID Plate. f+ 14 Proper bracing,anchors and guy lines.
vim'
r' S Safety belts,bars,locks and other passenger �/ 15 Adjacent hazards and interferences.
restraining devices.
Automatic and manual safety devices, / Guarding on motors,sprockets,chains,rails,belts
L• `/. 6 including safety lockout switches. �- ✓ 16 and drives.
` Fencing,guards,barricades,stairways andv 17 Brakes,hydraulic,pneumatic or mechanical,perm,
ramps. (. magnet.
Visible bolting,safety pins and keys. / Hydraulics and air systems,generator,generator
r ' 8 f/ 1 g grounded.
9 Observed device in operation. 19 Containment and seat numbers.
t / 10 Signage. 20 Manufacturer's Maintenance Checklist and manual.
Does the device require re-inspection by DPS or Third Party Yes No Re-inspected by: Date
Inspector? Check YES or NO and circle appropriate Inspector.
Comments below indicate items that require attention. Please check ✓ the appropriate box to indicate who made the comment;either Certified
Maintenance Mechanic(CMM)or DPS inspector(DPS). Also,check ✓ the Complete box once corrections are made.
CMM DPS. -� Complete
CMM DPS _!
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
The DPS Commissioner or his/her designee may cause a device to be taken out of service and not allowed to operate.CMMJ Yes No
shall Indicate whether or not the device was allowed tooperate at the referenced location.
This Amusement Device has been inspected by the Certified Maintenance Mechanic(CMM)and DPS inspector to the best of his/her abilities in
accordance with 520 CMR 5.00. The CMM is responsible for correcting items,herein,identified prior to operating the device.
Print and Sign Name of r .' ' f / Date
CMM.
Print Name of DPS
Inspector(s) �""" "'" 4' 1 Date
WHITE copy to DPS,CANARY copy to DPS inspector,PINK copy is retained by the Owner.
pAamusement device inspection checklist 2012 revised.docx
Commonwealth of Massachusetts
Department of Public Safety (DPS)
y�� a Amusement Device Inspection Checklist
Section I shall be completed by the Amusement Company
Owner or /' I Device Location t Date of Inspection i if
Company Name tt l ; n_11/ %'' ..t
Name of Device i ,� Serial Number DPS Company
Y} License No.
Manufacturers / Maximum Device USID t Is this first inspection?
1 / 1 /'� Speed(RPM) Number yes No
Section 2 shall be completed first by the Certified Maintenance Mechanic(CMM)following a thorough review of the device,then by the DPS
inspector. The CMM and DPS inspector shall indicate with a checkmark ,/if the item is satisfactory;with an X if unsatisfactory or
that the item does not apply(NA).
CMM DPS Inspection Checklist Items. CMM DPS Inspection Checklist Items.
Maintenance Records for the last 30 days �/ Signal systems,and control devices,including
1 including the daily maintenance logs. j./ L 11 emergency stops and overspeed systems.
2 Daily operator's log. % 12 Device structure and visible moving parts.
Operator training records and operator iBlocking and leveling systems.
3 identification. I v 13
,f ✓. 4 Manufacturer's Data Plate and USID Plate. 14 Proper bracing,anchors and guy lines.
Safety belts,bars,locks and other passenger / Adjacent hazards and interferences.
i 5 restraining devices. 1. V 15 I
Automatic and manual safety devices, Guarding on motors,sprockets,chains,rails,belts
V` 6 including safety lockout switches. t,. 16 and drives.
Fencing,guards,barricades,stairways and `/t Brakes,hydraulic,pneumatic or mechanical,perm,
7 ramps. /t 17 magnet.
✓ 8 Visible bolting,safety pins and keys. 18 Hydraulics and air systems,generator,generator
grounded.
L / 9 Observed device in operation. 19 Containment and seat numbers.
V ; 4
10 Signage. 20 Manufacturer's Maintenance Checklist and manual.
t`
Does the device require re-inspection by DPS or Third Party Yes No Re-inspected by: Date
Inspector? Check YES or NO and circle appropriate Inspector.
Comments below indicate items that require attention. Please check V the appropriate box to indicate who made the comment;either Certified
Maintenance Mechanic(CMM)or DPS inspector(DPS). Also,check v/ the Complete box once corrections are made.
CMM DPS
Complete
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
The DPS Commissioner or his/her designee may cause a device to be taken out of service and not allowed to operate.CMMI Yes No
shall Indicate whether or not the device was allowed tooperate at the referenced location.
This Amusement Device has been inspected by the Certified Maintenance Mechanic(CMM)and DPS inspector to the best of his/her abilities in
accordance with 520 CMR 5.00. The CMM is responsible for correcting items herein identified prior tooperating the device.
Print and Sign Name of f %' �' ,�,/~ / r
CMM. �lr�r..�,t�.r jl��i +,,l.�r� :`�t t, Date /
t` -�`1 ,
Print Name of DPS " ` `
Inspectors) { _ c�" 1 4 ..l r'?k'L' % Date ,>?�r
WHITE copy to DPS,CANARY copy to DPS inspector,PINK copy is retained by the Owner.
p:\amusement device inspection checklist 2012 revised.docx
44Y.
�5..."•".'Sic
Commonwealth of Massachusetts
Department of Public Safety (DPS)
01\ a`; Amusement Device Inspection Checklist
Section I shall be completed by the Amusement Company
Owner or �, Device Location r t Date of Inspection
Company Name /^• t /4,
Serial Number DPS Company `
Name of Device ' { ;� 1 License No.
Manufacturers — Maximum Device USID 1s this first inspection.
f.
Speed(RPM) Number !' j
Lr Yes 'No
Section 2 shall be completed first by the Certified Maintenance Mechanic(CMM)following a thorough review of the device,then by the DPS
inspector. The CMM and DPS inspector shall indicate with a checkmark ✓if the item is satisfactory;with an X if unsatisfactory or
that the item does not apply(NA).
CMM DPS Inspection Checklist Items. CMM DPS Inspection Checklist Items.
Maintenance Records for the last 30 days ^f e Signal systems,and control devices,including
L I including the daily maintenance logs. >.' �t i j %< I I emergency stops and overspeed systems.
1
f. 2 Daily operator's log. 12 Device structure and visible moving parts.
« Operator training records and operator 13 Blocking and leveling systems.
3 identification.
Manufacturer's Data Plate and USID Plate. l ' 14 Proper bracing,anchors and guy lines.
t1 1� 4 1-� �f
1Safety belts,bars,locks and other passenger 15 Adjacent hazards and interferences.
jJ 1 t., 5 restraining devices. L� t /�
pAutomatic and manual safety devices, j j Guarding on motors,sprockets,chains,rails,belts
6 including safety lockout switches. f' J { �' 16 and drives.
1 /r7
Fencing,guards,barricades,stairways and 17 Brakes,hydraulic,pneumatic or mechanical,perm,
! ramps. t / }.f + magnet.
Visible bolting,safety pins and keys. Hydraulics and air systems,generator,generator
> $ f f) 18 grounded.
L%
9 Observed device in operation. { 19 Containment and seat numbers.
10
Signage. f�` 20 Manufacturer's Maintenance Checklist and manual.
Jam;'
Does the device require re-inspection by DPS or Third Party Yes No Re-inspected by: Date
Inspector? Check YES or NO and circle appropriate Inspector.
Comments below indicate items that require attention. Please check ✓ the appropriate box to indicate who made the comment;either Certified
Maintenance Mechanic(CMM)or DPS inspector(DPS). Also,check ✓the Complete box once corrections are made.
CMM DPS ' Complete
r
,
CMM DPS ,J
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
The DPS Commissioner or his/her designee may cause a device to be taken out of service and not allowed to operate. CMM Yes No
shall Indicate whether or not the device was allowed tooperate at the referenced location.
This Amusement Device has been inspected by the Certified Maintenance Mechanic(CMM)and DPS inspector to the best of his/her abilities in
accordance with 520 CMR 5.00. The,CMM is responsible for,correcting items herein identified prior to operating the device.
Print and Sign Name of /
CMM. ' Date
Print Name of DPS Date
Inspector(s)
WHITE copy to DPS,CANARY copy to DPS inspector,PINK copy is retained by the Owner.
pAamusement device inspection checklist 2012 revised.doex
Commonwealth of Massachusetts
��1 Department of Public Safety (DPS)
shy a Amusement Device Inspection Checklist
6SsbW 3�?`^0C
Section 1 shall be completed by the Amusement Company
Owner or Device Location yt - Date of Inspection /
Company Name
Name of DeviceL Serial Number DPS Company
/ License No. i Z
j Maximum Device USID Is this first inspection?
Manufacturers , , !
Speed(RPM) Number
+f J ��� Yes No `
Section 2 shall be completed first by the Certified Maintenance Mechanic(CMM)following a thorough review of the device,then by the DPS
inspector. The CMM and DPS inspector shall indicate with a checkmark Vif the item is satisfactory; with an X if unsatisfactory or
that the item does not apply(NA).
CMM DPS Inspection Checklist Items. CMM DPS Inspection Checklist Items.
/ Maintenance Records for the last 30 days /, Signal systems,and control devices,including
��' 1 including the daily maintenance logs. �) j' t i' 1 l emergency stops and overspeed systems.
Daily operator's log. f' 12 Device structure and visible moving parts.
3 Operator training records and operator L , 13 Blocking and leveling systems.
r ; identification.
Manufacturer's Data Plate and USID Plate. r 14 Proper bracing,anchors and guy lines.
V i / 4 v
1 r, Safety belts,bars,locks and other passenger / 15 Adjacent hazards and interferences.
��'v t ,i/- 5 restraining devices. I�
Automatic and manual safety devices, t Guarding on motors,sprockets,chains,rails,belts
6 including safety lockout switches. ; r J /,l at 16 and drives.
Fencing,guards,barricades,stairways and t Brakes,hydraulic,pneumatic or mechanical,perm,
ramps. l5 j w, 17 magnet.
Visible bolting,safety pins and keys. Hydraulics and air systems,generator,generator
r
i f 8 ' ' j j,� r 18 grounded.
! 9 Observed device in operation. t + f 19 Containment and seat numbers.
10 Signage. t 20 Manufacturer's Maintenance Checklist and manual.
Does the device require re-inspection by DPS or Third Party Yes No Re-inspected by: Date
Inspector? Check YES or NO and circle appropriate Inspector.
Comments below indicate items that require attention. Please check the appropriate box to indicate who made the comment;either Certified
Maintenance Mechanic(CMM)or DPS inspector(DPS). Also,check v/ the Complete box once corrections are made.
Complete
CMM DPS ,t t . C',0y i•.,r t t ,' s t t T O
CMM DPS
}
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
The DPS Commissioner or his/her designee may cause a device to be taken out of service and not allowed to operate. CMMYes No
shall Indicate whether or not the device was allowed tooperate at the referenced location.
This Amusement Device has been inspected by the Certified Maintenance Mechanic(CMM)and DPS inspector to the best of his/her abilities in
accordance with 520 CMR 5.00. The CMM is responsible for correcting items herein identified prior to operating the device.
Print and Sign Name of _ % ' ,r
t Date c /
CMM.
Print Name of DPS `
Inspector(s) Cf <. �._ . Date
- 4 �
WHITE copy to DPS,CANARY copy to DPS inspector,PINK copy is retained by the Owner.
p:\amusement device inspection checklist 2012 revised.docx
Commonwealth of Massachusetts
hi Department of Public Safety (DPS)
y J: Amusement Device Inspection Checklist
W �?
Section I shall be completed by the Amusement Company
Owner or Device Location t/ Date of Inspection
Company Name
Serial Number DPS Company `
Name of Device j, ,/j' 4 r 'I/1 f License No.
7 r` •fit
Maximum Device USID Is this first inspection?
Manufacturers , Speed(RPM) Number { �t; Vit. Yes No
Section 2 shall be completed first by the Certified Maintenance Mechanic(CMM)following a thorough review of the device,then by the DPS
inspector. The CMM and DPS inspector shall indicate with a checkmark ✓if the item is satisfactory; with an X if unsatisfactory or
that the item does not apply(NA).
CMM DPS Inspection Checklist Items. CMM DPS Inspection Checklist Items.
Of Maintenance Records for the last 30 days Signal systems,and control devices,including
v� j including the daily maintenance logs. i' 11 emergency stops and overspeed systems.
Daily operator's log. 12 Device structure and visible moving parts.
2 4', Blocking and systems.
Operator training records and operator \, 13 g g y
t 3 identification. L /
Manufacturer's Data Plate and USID Plate. r 14 Proper bracing,anchors and guy lines.
Safety belts,bars,locks and other passenger 15 Adjacent hazards and interferences.
t' S restraining devices.
Automatic and manual safety devices, ~� 16 Guarding on motors,sprockets,chains,rails,belts
6 including safety lockout switches. and drives.
Brakes,hydraulic,pneumatic or mechanical,peau,
Fencing,guards,barricades,stairways and 17
L"', 7 ramps. magnet.
Visible bolting,safety pins and keys. 18 Hydraulics and air systems,generator,generator
8 grounded.
Observed device in operation. ✓ 19 Containment and seat numbers.
` 9 G
-7 10 Signage. C 20 Manufacturer's Maintenance Checklist and manual.
,,7 Does the device require re-inspection by DPS or Third Party Yes No Re inspected by: Date
Inspector? Check YES or NO and circle appropriate Inspector.
Comments below indicate items that require attention. Please check✓the appropriate box to indicate who made the comment;either Certified
Maintenance Mechanic(CMM)or DPS inspector(DPS). Also,check ✓the Complete box once corrections are made.
CompleW,
r 4
CMM bPS�' ��itf-4�•,t.,!" 'fir. , ,.tik
CMM DPS 1
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
The DPS Commissioner or his/her designee may cause a device to be taken out of service and not allowed to operate. CMM Yes No
shall Indicate whether or not the device was allowed tooperate at the referenced location. i
This Amusement Device has been inspected by the Certified Maintenance Mechanic(CMM)and DPS inspector to the best of his/her abilities in
accordance with 520 CMR 5.00. The CMM is responsible for correcting items herein identified prior to operating the device.
Print and Sign Name of f Date
CMM. t r r i l J L
Print Name of DPSDate i
.� y' 1 i - / t • '
Inspector(s) /L, ,
Ile- �t ;• Ir"fi<< t' `�1� ,ar �. r ,,P lr• t�;i �� I fi
WHITE copy.todSPS,CANARY copy to-DPS inspector,PINK copy is retained by the Owner.
p:\amusement device inspection checklist 2012 revised.docx
`5'"" "• is
4?t Commonwealth of Massachusetts
l
Vitt' j�� Department of Public Safety (DPS)
Amusement Device Inspection Checklist
Section 1 shall be completed by the Amusement Company
Owner or Device Location Date of Inspection ;
Company Name
Name of Device Serial Number DPS Company t ,
License No. i
Manufacturers / Maximum Device USID Is this first inspection?
1 / L_ Speed(RPM) Number f jL`j j Yes No
G'
Section 2 shall be completed first by the Certified Maintenance Mechanic(CMM)following a thorough review of the device,then by the DPS
inspector. The CMM and DPS inspector shall indicate with a checkmark v/if the item is satisfactory; with an X if unsatisfactory or
that the item does not apply(NA).
CMM DPS Inspection Checklist Items. CMM DPS Inspection Checklist Items.
Maintenance Records for the last 30 days Signal systems,and control devices,including
1 including the daily maintenance logs. 11 emergency stops and overspeed systems.
1 2 Daily operator's log. 12 Device structure and visible moving parts.
3
Operator training records and operator 13 Blocking and leveling systems.
identification. 1:
4 Manufacturer's Data Plate and USID Plate. f' , 14 Proper bracing,anchors and guy lines.
/ 5 Safety belts,bars,locks and other passenger i` Adjacent hazards and interferences.
/ restraining devices. t 1 15
6 Automatic and manual safety devices, Guarding on motors,sprockets,chains,rails,belts
1 f including safety lockout switches. tr f 16 and drives.
f 7 Fencing,guards,barricades,stairways and / Brakes,hydraulic,pneumatic or mechanical,perm,
(. V ramps. 1,; i7 magnet.
8 Visible bolting,safety pins and keys. 18 Hydraulics and air systems,generator,generator
V' 1 grounded.
9 Observed device in operation. Containment and seat numbers.
tf t c 19
10
Signage. i f 20 Manufacturer's Maintenance Checklist and manual.
" w
Does the device require re-inspection by DPS or Third Party Yes No Re-inspected by: Date
Inspector? Check YES or NO and circle appropriate Inspector.
Comments below indicate items that require attention. Please check ,/ the appropriate box to indicate who made the comment;either Certified
Maintenance Mechanic(CMM)or DPS inspector(DPS). Also,check ,/ the Complete box once corrections are made.
CMM rDff , r Complete
H
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
The DPS Commissioner or his/her designee may cause a device to be taken out of service and not allowed to operate. CMM Yes No
shall Indicate whether or not the device was allowed tooperate at the referenced location.
This Amusement Device has been inspected by the Certified Maintenance Mechanic(CMM)and DPS inspector to the best of his/her abilities in
accordance with 520 Q R 5.00. The CMM is responsible for correcting,items herein identified prior to operating the device.
Print and Sign Name of ,' ;' <' ;f i '
CMM. 1. '' x-c a.s r° <• '� / Date
Print Name of DPS
Inspectors) Date
WHITE copy to DPS,CANARY copy to DPS inspector,PINK copy is retained by the Owner.
pAamusement device inspection checklist 2012 revised.docx
Commonwealth of Massachusetts
W1 I Department of Public Safety (DPS)
Amusement Device Inspection Checklist
Section I shall be completed by the Amusement Company
Owner or
Device Location ? Date of Inspection
Company Name
' Serial Number DPS Company
Name of Device `
f i
i�••r , s� � i�.t License No.
Manufacturers Maximum Device USID Is this first inspection?
t i Speed(RPM) Number Yes a No
Section 2 shall be completed first by the Certified Maintenance Mechanic(CMM)following a thorough review of the device,then by the DPS
inspector. The CMM and DPS inspector shall indicate with a checkmark ✓if the item is satisfactory;with an X if unsatisfactory or
that the item does not apply(NA).
CMM DPS Inspection Checklist Items. CMM DPS Inspection Checklist Items.
. r Maintenance Records for the last 30 days Signal systems,and control devices,including
including the daily maintenance logs. �� 1 1 emergency stops and overspeed systems.
2 Daily operator's log. 12 Device stricture and visible moving parts.
/ Operator training records and operator Blocking and leveling systems.
3 identification. 13
4 Manufacturer's Data Plate and USID Plate. r i 14 Proper bracing,anchors and guy lines.
t�
if, 5 Safety belts,bars,locks and other passenger 15 Adjacent hazards and-interferences.
A restraining devices. t
6 Automatic and manual safety devices, 16 Guarding on motors,sprockets,chains,rails,belts
/ including safety lockout switches. ;/' and drives.
7 Fencing,guards,barricades,stairways and 17 Brakes,hydraulic,pneumatic or mechanical,perm,
ramps. magnet.
8 Visible bolting,safety pins and keys. 1 g Hydraulics and air systems,generator,generator
! grounded.-
9 Observed device in operation. 19 Containment and seat numbers.
L
10 Signage. 20 Manufacturer's Maintenance Checklist and manual.
` Does the device require re-inspection by DPS or Third Party Yes No Re-inspected by: Date
Inspector? Check YES or NO and circle appropriate Inspector.
Comments below indicate items that require attention. Please check ✓ the appropriate box to indicate who made the comment;either Certified
Maintenance Mechanic(CMM)or DPS inspector(DPS). Also,check ✓ the Complete box once corrections are made.
CMM DPS t ? ; 4
Complete
CMM DPS E Il
CMM DPS -
CMM DPS _
CMM DPS — f
CMM DPS
CMM DPS
CMM DPS
The DPS Commissioner or his/her designee may cause a device to be taken out of service and not allowed to operate. CMM Yes No
shall Indicate whether or not the device was allowed tooperate at the referenced location.
This Amusement Device has been inspected by the Certified Maintenance Mechanic(CMM)and DPS inspector to the best of his/her abilities in
accordance with 520 CMR 5.00. The.CMM is responsible for correcting items herein identified prior to operating the device.
Print and Sign Name of
Date
CMM. ae l
i
Print Name of DPS
Inspector(s) Date
WHITE copy to DPS,CANARY copy to DPSii�spector-,-PINK copy is retained by the Owner.
pAamusement device inspection checklist 2012 revised.docx
Commonwealth of Massachusetts
iii Department of Public Safety (DPS)
y; = Amusement Device Inspection Checklist
c
Section 1 shall be completed by the Amusement Company
Owner or / Device Location t Date of Inspection
Company Name �� ; _E 1, i e >L j'!/jx}f'• ,t! t ,'
Name of DeviceI Serial Number DPS Company ,f '
License No.
Manufacturers t //"
Maximum Device USID _ Is this first inspection?
f%�� , 1, Speed(RPM) Number '.-'f, ,/ yesNo
.I"✓ l,I i �! . , t
Section 2 shall be completed first by the Certified Maintenance Mechanic(CMM)following a thorough review of the device,then by the DPS
inspector. The CMM and DPS inspector shall indicate with a checkmark /if the item is satisfactory;with an X if unsatisfactory or
that the item does not apply(NA).
CMM DPS Inspection Checklist Items. CMM DPS Inspection Checklist Items.
I I t Maintenance Records for the last 30 days / Signal systems,and control devices,including
t + I including the daily maintenance logs. ti` I I emergency stops and overspeed systems.
�✓/ f� 2 Daily operator's log. ( r' 12 Device structure and visible moving parts.
I Gr'
r 3 Operator training records and operator Blocking and leveling systems.
L1 identification. U' / 13
4 Manufacturer's Data Plate and USID Plate. - 14 Proper bracing,anchors and guy lines.
5 Safety belts,bars,locks and other passenger 15 Adjacent hazards and interferences.
restraining devices. Li '
r� Automatic and manual safety devices, Guarding on motors,sprockets,chains,rails,belts
including safety lockout switches. L .' V r 16 and drives.
Fencing,guards,barricades,stairways and 1 17 Brakes,hydraulic,pneumatic or mechanical,perm,
7 ramps. L/,`� t.J �� magnet.
8 Visible bolting,safety pins and keys. * r 1 g Hydraulics and air systems,generator,generator
i/ ' grounded.
9 Observed device in operation. 1/ Containment and seat numbers.
19
V / 10 Signage. Manufacturer's Maintenance Checklist and manual.
f J" 20
Does the device require re-inspection by DPS or Third Party Yes No Re-inspected by: Date
Inspector? Check YES or NO and circle appropriate Inspector.
Comments below indicate items that require attention. Please check ,/ the appropriate box to indicate who made the connnent;either Certified
Maintenance Mechanic(CMM)or DPS inspector(DPS). Also,check ,/ the Complete box once corrections are made.
CMM DPS Complete
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
The DPS Commissioner or his/her designee may cause a device to be taken out of service and not allowed to operate. CMM Yes No
shall Indicate whether or not the device was allowed tooperate at the referenced location.
This Amusement Device has been inspected by the Certified Maintenance Mechanic(CMM)and DPS inspector to the best of his/her abilities in
accordance with 520 CM'k 5.00. The.CMM-is responsible for correcting items herein identified prior to operating the,device.,
Print and Sign Name of '� / Date
{ t� /
CMM. I
,,b f �.,1 4Iy r -r ( fVii/ `<
Print Name of DPS r t
Inspectors) Date 1
WHITE copy to DPS,CANARY copy to DPS inspector,PINK copy is retained by the Owner.
pAarnusernent device inspection checklist 2012 revised.docx
Commonwealth of Massachusetts
N ►A Department of Public Safety (DPS)
y,� D Amusement Device Inspection Checklist
Section I shall be completed by the Amusement Company
Owner or { J Device Location 1 Date of Inspection
Company Name
Name of Device ,l Serial Number DPS Company ^ /
a,(.:•11 C.^ License No.
Manufacturers Maximum Device USID Is this first inspection?t > ! t Speed(RPM) Number l CA i''
{ Yes "No
Section 2 shall be completed first by the Certified Maintenance Mechanic(CMM)following a thorough review of the device,then by the DPS
inspector. The CMM and DPS inspector shall indicate with a checkmark ✓if the item is satisfactory;with an X if unsatisfactory or
that the item does not apply(NA).
CMM DPS Inspection Checklist Items. CMM DPS Inspection Checklist Items.
Maintenance Records for the last 30 days Signal systems,and control devices,including
,,a,,, '' I including the daily maintenance logs. ,. I I emergency stops and overspeed systems.
x{{� 2 Daily operator's log. ' 12 Device struchire and visible moving parts.
t
i Operator training records and operator Blocking and leveling systems.
1. � 3 identification. 13
r ' 4 Manufacturer's Data Plate and USID Plate. t 14 Proper bracing,anchors and guy lines.
t.
5 Safety belts,bars,locks and other passenger 15 Adjacent hazards and interferences.
restraining devices.
6 Automatic and manual safety devices, 16 Guarding on motors,sprockets,chains,rails,belts
l� }( including safety lockout switches. t% and drives.
( � Fencing,guards,barricades,stairways and Brakes,hydraulic,pneumatic or mechanical,perm,
7 ramps. ✓ 17 magnet.
g Visible bolting,safety pins and keys. 18
Hydraulics and air systems,generator,generator
` grounded.
9 Observed device in operation. r' 19 Containment and seat numbers.
j' 10 Signage. L J 20 Manufacturer's Maintenance Checklist and manual.
Does the device require re-inspection by DPS or Third Party Yes No Re-inspected by: Dace
Inspector? Check YES or NO and circle appropriate Inspector.
Comments below indicate items that require attention. Please check v/ the appropriate box to indicate who made the comment; either Certified
Maintenance Mechanic(CMM)or DPS inspector(DPS). Also,check ,/ the Complete box once corrections are made.
CMMComplete
CMM 'DPS `1 •44 tt
e :•P-.�3/r (' i��lit. �:t� ,c i r r ,,� ' "�. ��
CMM DPS ! i
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
The DPS Commissioner or his/her designee may cause a device to be taken out of service and not allowed to operate. CMM Yes No
shall Indicate whether or not the device was allowed tooperate at the referenced location.
This Amusement Device has been inspected by the Certified Maintenance Mechanic(CMM)and DPS inspector to the best of his/her abilities in
accordance with 520 CMR 5.00. The,CMM is-fesponsible for correcting items herein identified prior to operating the device.
Print and Sign Name of ? f l /
1 , j Date
/
CMM. rl.'�-�.alt r' v ;�'; ir• �.�
Print Name of DPS
Inspector(s) 1 1 y`` ! J' Date f j+
' .� , i l J`Jt
WHITE copy`to D�'S,CANARY copy to DPS inspector,PINK copy is retained by the Owner.
p:\amusement device inspection checklist 2012 revised.docx 1
Commonwealth of Massachusetts
Department of Public Safety (DPS)
s�ti a Amusement Device Inspection Checklist
lv �
Section 1 shall be completed by the Amusement Company
Owner or ! Device Location t ! Date of Inspection
Company Name
Name of Device ' Serial Number DPS Company '
License No.
Manufacturers ! Maximum Device USID Is this first inspection?
/ 1 f' Speed(RPM) Number >
.t/ +• �+ t•(. }� ' Yes No
Section 2 shall be completed first by the Certified Maintenance Mechanic(CMM)following a thorough review of the device,then by the DPS
inspector. The CMM and DPS inspector shall indicate with a checkmark ✓if the item is satisfactory;with an X if unsatisfactory or
that the item does not apply(NA).
CMM DPS Inspection Checklist Items. CMM DPS Inspection Checklist Items.
� Maintenance Records for the last 30 daysSignal systems,and control devices,including
I including the daily maintenance logs. ��. 11 emergency stops and overspeed systems.
r Daily operator's log. I f, 12 Device structure and visible moving parts.
2
4'
3 Operator training records and operator + 13 Blocking and leveling systems.
identification.
4 Manufacturer's Data Plate and USID Plate. .` 14 Proper bracing,anchors and guy lines.
' Safety belts,bars,locks and other passenger ,i Adjacent hazards and interferences.
f fr 5 restraining devices. ' `f' 1 5
f" Automatic and manual safety devices, 16 Guarding on motors,sprockets,chains,rails,belts
6 including safety lockout switches. (i and drives.
Fencing,guards,barricades,stairways and Brakes,hydraulic,pneumatic or mechanical,perm,
r� ramps. / 1 magnet.
8 Visible bolting,safety pins and keys. 18 Hydraulics and air systems,generator,generator
grounded.
Observed device in operation. 19
Containment and seat numbers.
Signage. 20 Manufacturer's Maintenance Checklist and manual.
IQ ✓'�
Does the device require re-inspection by DPS or Third Party Yes No Re-inspected by: Date
Inspector? Check YES or NO and circle appropriate Inspector.
Comments below indicate items that require attention. Please check ✓ the appropriate box to indicate who made the comment; either Certified
Maintenance Mechanic(CMM)or DPS inspector(DPS). Also,check ✓ the Complete box once corrections are made.
�, Complete
CMM DPS l' j),�� r , i d3-
CMM �DPS /;�
\4 1
CMM -`DPS
s +
CMM '_DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
The DPS Commissioner or his/her designee may cause a device to be taken out of service and not allowed to operate.CMM Yes No
shall Indicate whether or not the device was allowed tooperate at the referenced location.
This Amusement Device has been inspected by the Certified Maintenance Mechanic(CMM)and DPS inspector to the best of his/her abilities in
accordance with 520 CMR 5.00. The CMM_is responsible for correcting items herein identified prior to operating the device.
Print and Sign Name of
CMM. a;+�r ;.;rte:.,tf_,• i t f> Date
,-
Print Name of DPS
:r Date
Inspector(s) ,/ / } ';i, °"! t ' • " ' ' '
WHITE copy to DPS,CANAIRY copyrto"DPS inspector,PINK copy is retained by the Owner.
pAamusetnent device inspectidil hecklist 2012 revised.doex
Commonwealth of Massachusetts
Department of Public Safety (DPS)
Amusement Device Inspection Checklist
Section 1 shall be completed by the Amusement Company
Owner or Device Location j Date of Inspection t
Company Name
Name of Device jj y /, Serial Number DPS Company r %
A,� 1, 7 1 I li�, ,�7 '�k License No.
Manufacturers
Maximum Device USID Is this first inspection?
b
N
Speed(RPM) umer
f Yes I No �
s
Section 2 shall be completed first by the Certified Maintenance Mechanic(CMM)following a thorough review of the device,then by the DPS
inspector. The CMM and DPS inspector shall indicate with a checkmark ✓if the item is satisfactory;with an X if unsatisfactory or
that the item does not apply(NA).
CMM DPS Inspection Checklist Items. CMM DPS Inspection Checklist Items.
' Maintenance Records for the last 30 days f, F12 Signal systems,and control devices,including
including the daily maintenance logs. / t �` emergency stops and overspeed systems.
f / 2 Daily operator's log. �� Device structure and visible moving parts.
3Operator training records and operator ' Blocking and leveling systems.
identification. 1
4 Manufacturer's Data Plate and USID Plate. 14 Proper bracing,anchors and guy lines.
5 Safety belts,bars,locks and other passenger 15 Adjacent hazards and interferences.
restraining devices. 1r
Automatic and manual safety devices, " 16 Guarding on motors,sprockets,chains,rails,belts
6 including safety lockout switches. if l and drives.
Fencing,guards,barricades,stairways and ! a 17 Brakes,hydraulic,pneumatic or mechanical,pe,in,
ramps. magnet.
Visible bolting,safety pins and keys. 18 Hydraulics and air systems,generator,generator
ii 8 grounded.
9 Observed device in operation. �" 19 Containment and seat numbers.
Ll 10
yam.
Signage. / 20 Manufacturer's Maintenance Checklist and manual.
Does the device require re-inspection by DPS or Third Party Yes No Re-inspected by: Date
Inspector? Check YES or NO and circle appropriate Inspector.
Comments below indicate items that require attention. Please check ✓ the appropriate box to indicate who made the comment; either Certified
Maintenance Mechanic(CMM) or DPS inspector(DPS). Also,check ✓ the Canplete box once corrections are made.
CMM DPS Complete
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
The DPS Commissioner or his/her designee may cause a device to betaken out of service and not allowed to operate. CMMI Yes I No
shall Indicate whether or not the device was allowed tooperate at the referenced location.
This Amusement Device has been inspected by the Certified Maintenance Mechanic(CMM)and DPS inspector to the best of his/her abilities in
accordance with 520 CMR 5.00. The CMM is responsible for correcting items herein identified prior to operating the device.
Print and Sign Name of - /r f' f
Date
CMM. ?, ,. t 1 j s.�..i/ 1�' ." / s e 1,:
Print Name of DPS` '4/
�
Inspector(s) Date, Ji'>� V�'In 4� - r .
r
WHITE copy to DPS,eANXRY copy t0`DPS inspector,PINK copy is retained by the Owner. l
pAamusement device inspection checklist 2012 revised.docx
i
�5 Commonwealth of Massachusetts
Department of Public Safety (DPS)
Amusement Device Inspection Checklist
Section 1 shall be completed by the Amusement Company
Device Location l t ;a:te:ofInspectionOwner or ''Company Namei /�`ri,% ; ??•"i`aSerial Number PS Company
Name of Device License No.
t I USID Is this first inspection?
Maximum Device
Manufacturers ' Number
J Speed(RPM) Yes No
Section 2 shall be completed first by the Certified Maintenance Mechanic(CMM)following a thorough review of the device,then by the DPS
inspector. The CMM and DPS inspector shall indicate with a checkmark v,/if the item is satisfactory;with an X if unsatisfactory or
p NA .
es not 1 )
that the item do apply(
CMM DPS Inspection Checklist Items. CMM DPS Inspection Checklist Items.
Signal systems,and control devices,including
i / 1 Maintenance Records for the last 30 days 11 emergency stops and overspeed systems.
including the daily maintenance logs. 12 Device stricture and visible moving parts.
( j 2 Daily operator's log. �;
!J J Blocking and leveling systems.
Operator training records and operator s i t�/ 13
3
J identification. and a lines.
4 Ma
mifacturer's Data Plate and USiD Plate. f 14 Proper bracing,anchorsg y
5 Safety belts,bars,locks and other passenger
15 Adjacent hazards and interferences.
restraining devices.
Guarding on motors,sprockets,chains,rails,belts
Automatic and manual safety devices,
6 16 and drives.
( l including safety lockout switches.
Fencing,guards,barricades,stairways and 17 Brakes,hydraulic,pneumatic or mechanical,pens,
/ magnet.
7
4 (f ramps.
Visible bolting,safety pins and keys. 1 g Hydraulics and air systems,generator,generator
8 grounded.
i Containment and seat numbers.
Observed device in operation. 19
t/ Manufacturer's Maintenance Checklist and manual.
/
10 Signage. 20
�e
No Re-inspected by:
Yes Re ins e
Third Pa P
Does the device require re-inspection by DPS or Party
Inspector? Check YES or NO and circle appropriate Inspector.
Comments below indicate items that require attention. Please check ✓ the appropriate box to indicate who made the comment;either Certified
Maintenance Mechanic(CMM)or DPS inspector(DPS). Also,check ✓ the Comj.?lete box once corrections are made. Complete
CMM tDPS �
i
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
CMM DPS
The DPS Commissioner or his/her designee may cause a device to be taken out of service and not allowed to operate.CMM Yes No
shall Indicate whether or not the device was allowed tooperate at the referenced location.
This Amusement Device has been inspected by the Certified Maintenance Mechanic(CMM)and DPS inspector tothe best of his/her abilities in
accordance with 520 CMR 5.00. The CMM is responsible for correcting items herein identified prior to operating the device. f .
j.
Print and Sign Name of Date ` ,.
CMM.
Print Name of DPS Date 1 r t
Inspector(s) .f 1'k a .
inspector,PINK co is retained b the Owner. l
WHITE copy to DPS;C�NARYfcopy to DPSI � p copy Y
pAamusement device inspection checklist 2012 revised.docx