HomeMy WebLinkAboutFire Protection Impairment Permit - Permits - 9/27/2019 1600 Osgood$1,LLG Form WOZ04A Form used with OZ04
1600 Osgood St. FIRE PROTECTION IMPAIRMENT PERMIT Issue 41
N.Andover,MA 2116[05
FOR NAFD LIEUTENANT ON DUTY
REQUEST FOR CONTROLLED SPRINKLER `The IMPAIRMENT
SHUTDOWN Completes this part.
;F.
Faxes It to the NAFD Lieutenant on duty at
The PERSON requesting tile IMPaIrMONA shall.' 7 688.9 lent
978-688-9694 one day before the Impairment.
a)Complete,the applicable italiclZed Parts Of this Informs NAFD at 978-688-9590.
form, PL...... .........b
b)Sign the form.
0, UM
n)olve,the form to the Impairment Coordinator 24
hours in advance. (Enter Condition A 13,C.D,E.or F per Col.1 In QZ04 table)
d)Follow any special requirements. LESS THAN 4 HOURS
1, What will be lmpaire0(sprinkler zone, equipment, etc.) Precautions taken:
Sprinkler one M-04
2. What will the impairment affect?(floors,cols, areas, etc.) Comments:
Building#21 I't Floor
Building#21 td Floor 4 14OURS OR MORE
Building#21 3d Floor Pre ution taken(check one):
t7d.
_�A fire watch,or a special arrangement with
Chock if, emergency responders (I'4T1(L4vM,)
__A temporary water supply
—Audio visual system(fire alarm)Impaired --Elimination of potential ignition sources,and
limitation of available fuel
--Drawing attached(fax a drawing of the buildinglarea Evacuation of affected areas
affected,if necessary) Other precaution(s)taken:
3. When will the impairment begin?
Starts approx.at 8:00 AM.9126119
2�4y, Date:9126/19
(Signature of Imrairment Coordinator, or delegate.)
4.How long will the impairment last?
NAFD
Lasts until approx.4:00 PM 9126119 a Completes this part
o Faxes it to 978-681-SiO9
5.Are any special precautions boinq taken?(Give relevant o Informs the impairment Coordinator at 978-
details.) fig % 4
Date; P;V
I have a J7pr—ovod the impairment.
Date-_--
have,rejected the impairment,
Ilk
TO.-978-0,15-7202 Dato:91?6119 he IMPAIRMENT COORDINATOR
0 Completes tills part
ignaturo and Tel.4 of person planning Impairroent *Faxes It to the NAFD Lieutenant oil duty,
ed Dowgiett 978-668-9594, after the impairment
T
q
Printed narna of person pirinning lippairmont 134
WlI IUl 'k
Dowgiert Construction
Company represented __Date
(Signattt f Impatrinent oordinator,or
Document user must contact the process ovalerto verify the latest-daW Issue is being used.