HomeMy WebLinkAbout0287 IYANNOUGH ROAD/RTE 28 (5) ��7 s . . � U �� ��
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PROJECT
NAME:
ADDRESS:
PERMIT# �0 (H o 75 09
PERMIT DATE: < < I l a l
LARGE ROLLED PLANS ARE IN:
BOX
SLOT
L
Data entered in MAPS program on:
BY:
q/wpfiles/forms/archive
TOWN OF rRNSTABLE BUILDING PERMIT APPLICATION
Map Parcel 3�� Application # �
Health Division Date Issued
Conservation Division Application Fee 6
Planning Dept. Permit Fee 17�
Date Definitive Plan Approved by Planning Board / 1
Historic - OKH _ Preservation/ Hyannis
y
7
Project Street Address 4 T l nt TAWOV64 ? t►�
Village 01
Owner yll6-4v",&SO t? Address SAS'
Telephone ?-7
Permit Request
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new -
Zoning District ,d�Z.%dA4_Flood Plain Groundwater Overlay C;s r-1) ...�
Project Valuatio d Construction Type ;}
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach'Oporting Documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) �J
Age of Existing Structure Historic House: ❑Yes��No On Old King's Highways❑Yb8IE
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other 11/'dyljl" _S ` 4
Basement Finished Area (sq.ft.) 62 Basement Unfinished Are pq.ft)
Number of Baths: Full: existing new Half: existing �/ new
Number of Bedrooms: existing —new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial UPYes ❑ No If yes, site plan review #
Current Use iM'j Proposed Use
APPLICANT INFORMATION
ibm 41af- Lwii �.M$ ER OR HOMEOWNER)
Name C�� T CJ�� '1�1QC�"� ; Telephone Number � � 45'� ��p
Address 0 q License # li �0 o�oq�
s �t, 01
Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE �"' DATE ID'' "I`f
h
1
I
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
f- •. Y
i
DATE OF INSPECTION:
ji FOUNDATI.ONi .-f s,,.,w. f•�4,--,vu-i7,)..
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
t '
}
DATE CLOSED OUT
ASSOCIATION PLAN NO.
F
a
zs Cr�mrtxarisc�th o�?�rrssuehus�lts '
Deparhnent of firdrrstrud Accidents
-- - (KWe OfInVesti lens
600#�zw&,rgtba&reel
Bastor�,.MA 02UJ
wn*t�t.rtrass gosr�'ur
Workers' Campensation lusurance Affidavit:Builders/ContractursfFAectricians/Plumbers
Applicant Laformation Please Print Legibly
Nam(Busfii ftanizati tluan_ 1� _�&IIA��
Address:
CityfStatrlZip= cS 7 Phont-4
Are you an employer?Cheekthe appropriate boa: T , of
4_ ❑ I arty a general contractor and I project� � �=
I_�] I am a employer witft 6- New txmstzuction
fu.I and/or -fmae.* have hired the sub-��tam
employees listen on the attached sheet" 7- ❑Remodeling
2_El I am a sore proprietor or partner- These sub-contractors have
slim m!,d/lave no employeesg- ❑Demolition
w fvr me in an c ci r_ employees and have workers'
orkirig y � t3 4_ ❑Building ad'difion
UN,To workers' camp:insriimnce comp_,insurance_l
5_❑ Ode are a corporation and its 10_❑Electrical repairs or additions
� --�
3_❑ I tall a homaouner doing all wadi officers/lava exercised their I I_.❑Plumbing repairs or additions -
myself [No uror.�s,camp_ c-1,5:ofe(4),and
12_.❑FDof repairs
i�,a�nre required_]1 c_1.52, §1(4},andwel>a��no
employees_[No Workers' 13_D Other
. comp_insnra require -]
*Amy alplirsf dirt checks boa�I nmst also fll out the section below showing iheir woikeis'compensation Policy infMrm
9 Eomeown---s vr.�o sionit dus s£idsvd iamrstimg they 21a lining sIT TIUffC anal then hire omride cOntractrrrs mrh
=C.ontca Tors tbst check thus boa m=attache d su additional sheet showing the name of the Wa- and state whetter tx mot dams eati a have
ewioyees_ If the sob cotitmctars have employees,dL4!y must piwide their workers'coal.policy I msber
I am an enTtoyem Reloty is the pa&cy anal joh site
information_
Insurance Company Dame_ /' G r✓1�✓Il L, =/lsLrr►74Y1 y
Policyfim
,or Self-insu U �,f 701 T�Z7^ 1 L� Expiration Date:
Job Site Address: �� �y G'N A,9 Cify/S tatelZip:!'�J�
Attach a cope of the workers'compensation policy dedaration page(showing the policy number and expiration date).
Failure to see coverage as requ:iredunckT Section 25A of MUL c_ 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one—year-imprisonment as well as civil penalties in the.form of a STOP WORK ORDER and a fine
of up.to$250.00 a_day against the;violator_ Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby certify racier t-hepeans and ponalties of warp that the information pravided a re cs hw and correct
Sialattire: (' Bate:
Phone 9: J C�v �C7 --
- --- t7,,�ciad due ond}—Z}v not�rit�in fliis area#a ba ceirnp�eted by pity'ortolan-of 4'ciaL
City or Town- PerraitUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Departtnent 3'_Cifylrawa Clerk 4_Electrical inspector S.Plumbing build for
.6.Other
Contact Person: Phone#:
6
Information and Instructions n
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuantto this statute,an ernzployee is defined as".._every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer;or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the -
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or IocaI licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonweath for 2)ay
applicant who has.not produced acceptable evidence of compliance with the insurance.coverage required.-
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political siubdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance the insurance
requirements of this chapter have been presented to the contracting authority.-' 1,
---,applicants —
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone numbers)along with their ceri ric ut(s)of
izas=nce. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance- If an LLC or LLP does have
employees, a policy is required_ Be advised that this affidavit may be submifted to the Department of industrial
n.cciden�for confirmation of ins��ance coverage- Also be sure to sign and date the affid2vit_ 7.he a,. davit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obt__ili a workers'
compensation policy,please call the Department at the number listed below. Sell insured companies should enter their
self-insurance license number on ti!e approuriate line.
City or Town Officials
P1_:zse be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the,Office of Investigations has,to,contact you`regarding the applicant-
Please be sure to fill in the permit/lictase number which vri11 be used as a reference number. In add tim.an.applicant
That must submit multiple permitfEcense applications in any given year,need'only submit one a.f idavit indicarng current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
LoWn)."A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the
applicant as proof that a valid affiidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would lice to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Gomia nwman of Massachusetts • .
Depaz meat of indtzslHal;Accidents r ;
Gff!Qe of lqvestsotiQr�
600 wasbingtGn Strut
Boston,MA Q2 1 I I
T tL 4 6 17-72 7-4,QQ 0 W 4-06 or I-RT7-2V1ASSAFE
Reuse-d 4--24.07 Fax 9 617-727-7-749
• � .rt�asSga�r�ciia -
CERTIFICATE OF LIABILITY INSURANCE D�AT:E:(�IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND C . ON THE CERTIFICATE HOLDECERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRES
OR PRODUCER AND THE CERTIFICATE HOLDER.
4, IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUB ENTATtVE
terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to t
`i certificate holder in lieu of such endorsements. ROGATION IS WAIVED,subject to the
PRODUCER 9 he
CONTACT
DOWLING&ONEIL INS NAME:
973 IYANNOUGH ROAD PHONE FAX
(A/C,No,Ext):
(A/C,No):
HYANNIS,MA 02601 E-MAIL
22LGR ADDRESS:
INSURER(S)AFFORDING COVERAGE
INSURED NAIC#
HOLLY MANAGEMENT&SUPPLY CORPORATION INSURER A: ACE AMERICAN INSURANCE Co1.1pANY
INSURER B:
ti INSURER C:
297 NORTH STREET INSURER D:
HYANNIS,MA 02601 INSURER E:
COVERAGES INSURER F: "—"'
CERTIFICATE NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LIS
ANY REQUIREMENT,TERM OR CONDITION OF ANY.CONTRACT--
BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
REVISION NUMBER:
OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN.THE INSURANCE
AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY
PAID CLAIMS.
INSR
LTR TYPE OF INSURANCE ADD SUB POLICY EFF DATE POLICY EXP DATE
L R POLICY NUMBER (MMIDDIYYYY)GEN (MMIDDIYYYY)
ERAL LIABILITY LIMITS
COMMERCIAL GENERAL LIABILITY CH OCCURRENCE $
CLAIMS MADE ❑OCCUR. AMAGE TO RENTED
REMISES(Ea occurrence) $
ED EXP(Any one person) $
GEN'L AGGREGATE LIMIT APPLIES PER: ERSONAL&ADV INJURY
POLICY PROJECT LOC ENERAL AGGREGATE $
I
AUTOMOBILE LIABILITY RODUCTS-COMP/OP AGG $
ANY AUTO COMBINED SINGLE
ALL OWNED AUTOS LIMIT(Ea accident) $
SCHEDULE AUTOS BODILY INJURY $
HIRED AUTOS (Per person)
NON-OWNED AUTOS BODILY INJURY $
(Per accident)
PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIAB OCCUR
EXCESS LIAB CLAIMS-MADE EACH OCCURRENCE $
DEDUCTIBLE AGGREGATE $
RETENTION $ $
A WORKER'S COMPENSATION AND $
EMPLOYER'S LIABILITY Y/N UB-5B909707-14. 04/02/2014 04/02/2015 X' WC STATUTORY OTHER
ANY PROPERITOR/PARTNER/EXECUTIVE LIMITS
OFFICER/MEMBER EXCLUDED? NN/A
(Mandatory in NH) E.L.EACH ACCIDENT $ 1,000,000
If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/RESTRICTIONS/SPECIAL ITEMS E.L.DISEASE POLICY LIMIT $ 11000,000
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER
TOWN OF BARNSTABLE CANCELLATION
367 MAIN ST SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL B DELI D
IN ACCORDANCE WITH THE POLICY PROV
HYANNIS,MA 02601 AUTHORIZED REPRESENTATIVE
ACORD 25(2010/05) The ACORD name and logo are registered marks of'CORD 1988-2010 ACORD CORP
rig is reserved.
4 i
TVET° Town of Barnstable
Regulatory Services
rrsrnscs Thomas F.Geiler,Director
nsass.
'rEo Ik Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
hereby authorize cT �—r� to act on my behalf,
in aIl matters relative to work authorized by this building permit
(Address of Job)
Pool fences and alarms are the responsibility of the applicant. Pools
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Signature of Owner Signature of Applicant
r �l
Print Name Print Name
Date
Q:FORM&OWNERPERMISSIONPOOLS 6/2012
q4nNQ
Product
CP 643N
Firestop Collar ,.
Product description N
■ A ready-to-use firestop collar,made of a galvanized steel housing
Bomb.-
and intumescent inserts for firestopping combustible pipes ,
Product features
■ Ready-to-use collar
® No construction required
® Fast installation time
■ Adjustable mounting tabs
® Low profile for tight installations r a ,gam
a a., M, -
Areas of application
■ Firestopping combustible pipes up to 6"diameter in penetrations tTeChniCal Data, e 1 �j
through fire walls and floors pipe Collar Collar No.of
® Suitable for the following pipe materials: outside outside Height hooks and
® PVC,CPVC,ABS,PVDF,PP and FRPP Description dia(in.) dia.(in.) (in.) fasteners
For use With CP 643-50/1.5"N 1.4-2.0 2.8 0.9 2
® Concrete,mason wood floor and CP 643-63/2"N 2.0-2.5 . 3.4 1.3 2.
masonry, gypsum wall assemblies CP 643-90/3"N 2.6-3.6 4.9 1.7 3
® Wall and floor assemblies rated up to 4 hours CP 643-110/4"N 3.6-4.5 6.0 1.9 3
Types of installation CP 643-160/6"N 6.6 9.8 1.9 4
® Wall:two collars,one on each side Temperature resistance -40OF to 140OF(-40oC to 60oC)
■ Floor:one collar on underside(bottom) Intumescent activation Approx.392OF(200°C)
Expansion ratio(unrestricted) Up to 1:10
Example Approvals
■ Waste water pipes •California State Fire Marshal-No.4485-1200:113
■ Fresh water pipes No.4485-1200:131
City of New York-MEA 630-06-M
Tested in accordance with
•UL 1479 •ASTM E 814
psstFiP FIRESTOP DEVICE
oOo FOR USE IN THROUGH-PENETRATION FM- SYSTEM COMPATIs4E
FIRESTOP SYSTEMS
C SEE UL FIRE RESISTANCE DIRECTORY APPROVED
5N76
Installation instructions for CP MN
Notice Application of Firestop system 5. Fastening the CP 643N Firestop Collar. Only when
• Before handling,read Material Safety Data Sheet and 2. Seal the opening if required.Gaps maybe closed fastened properly can CP 643N offer protection
product label for safe usage and health information. with FS-ONE.The approved methods vary and are against fire.
• Instructions below are general guidelines—always given in the specific UL system. a. Mark the fastening points.
refer to the applicable drawing in the UL Fire 3. Close the CP 643N Firestop Collar.Place the b. Drill holes with a Hilt!rotary hammer drill(i.e.
Resistance Directory or Hilti Firestop Systems Guide CP 643N Firestop Collar around the plastic pipe TE 4-A18)or,depending on base material,fasten
for complete installation information and lock the closure by applying firm pressure until using Hilti powder-actuated tool.
it latches.
Opening c. To secure the CP 643N Firestop Collar,use Hilti
4. Attach fastening hooks.The fastening hooks can
1. Clean the plastic pipes.Expansion of the anchors/fasteners. .
intumescent material during a fire acts to close the be attached to various points on the metal housing.This allows the fastening points to be made to suit d. For maintenance reasons,a penetration can be
plastic pipe.Very dirty pipes(le:with remains of permanently marked with an identification plate and
must
h Th h in bl each case. e hooks mus available mortar)may lead to a delay in this closing action. the spacefastened in a visible position next to the seal.
Soiled plastic pipes should,therefore,be cleaned in be positioned as symmetrically as possible.The
the area where the CP 643N Firestop Collar is to be required number of fastening hooks is indicated on Not for use
installed. the packaging. With metal pipes
• In highly corrosive surroundings
x w
With'unapproved anchors/fasteners
Storage
Store only in the original packaging in a location
protected from moisture
1.Clean plastic pipe. 2.Close remaining gap to 3.Close collar. 4.Attach fastening hooks. 5.Fasten collar and
provide smoke and gas identification plate -
resistant seal. - (if required).
Hilti Firestop
® Saving Lives
through innovation
L and education '
Hilti. Outperform. Outlast.
Hihi,Inc.(U.S.)1-800-879-8000•www.us.hilti.com•en espanol 1-800-879-5000•Hilti Firestop Systems Guide
f
MSDS No.: 301
Revision No.: 001
Revision Date: 02/28/05
Page: 1 of 2
St
ar MATERIAL SAFETY DATA SFIEET 4. ,*
1
Product name: CP 643N Firestop Collar/CP 644 Firestop Collar
Description: Galvanized metal housing containing black polymer-bonded intumescent firestop material
Supplier: Hilti, Inc. P.O.Box 21148, Tulsa, OK 74121
Emergency#(Chem-Trec.): 1 800 424 9300(USA, PR,Virgin Islands, Canada); 001 703 527 3887(other countries)
INGREDIENTS ANDyEXPOSURE LIMITS
Not applicable. This product is considered to be an "article" as defined in the federal OSHA Hazard Communication Standard
29 CFR 1910.1200/1926.59.
w:HYSICALDA
l e ���OTA � �� � 7 �
Appearance: ` Metal collar/black firestop Odor-
material ` None
o-
Vapor Density:.(air=1) =, Not applicable Vap r Pressure . _;, Not applicable
Boiling Point: Not applicable VOC Content 7.6 g/I
Evaporation kate:, ti� Not applicable Solubility in Water � .� Not determined
LSpecifc Gravity. Not determined pH:' '� '"°" 1 ` Not applicable
.;•' »"" .Aso
FIRE,AND EXPLOSION HAZARD
Flash Point: k , Not applicable Flammable:Limits. Not applicable
Extinguishing Media: Use extinguishing media,appropriate for surrounding fire.
Special Firefighting None known.
Procedures:
i Unusual Fire and Explosion None known. Product serves as a Firestop; intumescent material inside the collar expands
Haiards ` ` when exposed to temperatures> 160°C/320°F.
,. `phREACTIVITY DATA , t r. ,iu a .
„Stability �' Stable. Hazardous Polymerization '. A Will not occur.
Incompatibility: r ._ w,; None known Decomposition Products. "" None known
�Conditi'ons tq_Avoid None known
+; . 5 �" HEALTH HAZARD DATA�� ,a+�� �' r �'°
Knowni3Hazards None known �Routes�of Exposure "' None known
Signs and Symptoms of None expected from routine use/installation according to manufacturer's specifications and
Exposure technical guides.
Carcincgeniclty No ingredients are classified as a carcinogen by IARC, NTP or OSHA.
Medical Conditions None known
=Aggravated byfxposure_ z
�'`� "-.M F1 ter • q• a9 h ^,"rae ;.°
EMERGENCY,AND FIRST AID PROCEDURES .. .. -
__ ._. _
'Eyes':" Immediately flush with plenty of water. Call a physician if symptoms occur.
Skin: .`ry Not applicable. Practice good hygiene; i.e. wash hands during breaks, before eating or
smoking, and after work.
Inhalation: t , ..v t � Not applicable.
f
Ingestion.�� ` w, Not a potential route of exposure
Other:, - Referral to a physician is recommended if there is any question about the seriousness of any
k injury/exposure.
HILTI 0 is a registered trademark of Hilti Corp.
CONTROL MEASURES ND PERSONAL PROTECTIVE EQUIPMENTS `
A e
Ventilation ,$ �T .M General(natural or mechanically induced fresh air movements).
Eye Protection: Not required, however, safety glasses should be worn in most industrial settings.
Skin Protection: - 7 None required; however, (cotton)gloves recommended.
,Res piratory Protections No respiratory protection is needed for normal application of this product.
PRECAUTIONS FOR SAFE HANDLING:AND.,USE=
[Handling and Storing Store in a cool dry area. Follow installation instructions.
Precautions:
Spill,Procedures: No special requirements.
REGULATORY:INFORyMATION
a,
_ y t
Hazard Communication This product is considered to be an "article" as defined in the federal OSHA Hazard
Communication Standard.
DOT-ShippIhg Name: Not regulated.
IATA/.ICAO Shipping Name ' Not regulated.
TSCA Inventory Status: Chemical components listed on TSCA inventory.
SARA Title 111,Section 313 ""' This product is classified as an "article" and is not subject to reporting under Section 313 of
SARA Title III (40 CFR Part 372).
"EPA Waste Codes) ,# Not regulated by EPA as a hazardous waste
Waste Disposal Methods Consult with regulatory agencies or your corporate personnel for. disposal methods that
comply with local, state, and federal safety, health and environmental regulations.
;_CONTACTS , ,
Customer Service 1 800 879 8000 Technical_Service , 1 800 879 8000
Health/Safe 1 800 879 6000 JerryMetcalf ^x6704
Emergency 1 800 424 9300(USA, PR,Virgin Islands, Canada); 001 703 527 3887(other countries)
The information and recommendations contained herein are based Upon data believed to be correct; however, no guarantee or
warranty of any kind expressed or implied is made with respect to the information provided.
MSDS 301, Page 2 of 2
Certificateof Compliance
Certificate Number 20069214-R15431 Page 1 of 1
Report Reference 2006 February 14
Issue Date 2006 February 14 U Underwriters
® L Laboratories Inc..
Issued to: H i Iti, Inc.
5400 S 122ND East Ave
Tulsa,OK 74146 USA
This is to certify that Firestop Devices
representative sainples of CP643N 50/1.5 in.,CP643N 63/2 in.,CP643N 90/3 in.and CP643N
110/4 in., CP643N 160/6 in., CP644 200/8 in.and CP644 250/10 in.
Have been investigated by Underwriters Laboratories Inc.®in
accordance with the Standard(s) indicated on this Certificate.
Standard(s)for Safety: ANSI/UL 1479,CAN/ULC-S115-05
Additional Information: CP 643N and CP 644 Firestop Collar for use in Through-Penetration Firestop
Systems as currently described in the UL Fire Resistance Directory.
Only those products bearing.the UL Classification Mark should be considered as being
covered by UL's Classification and Follow-Up Service.
The UL Classification Mark includes: UL in a circle symbol: with the word'
"CLASSIFIED" (as shown); a control number (may be alphanumeric) assigned by UL; a
statement to indicate the extent of UL's evaluation of the product;and, the product category
name(product identity)as indicated in the appropriate UL Directory.
Look for the UL Classification Mark on the product
Iss�: �. Reviewed b
Mona Cou oute Christoph J son
Underwriters Laboratories Inc. Underwrite oratories Inc.
r -
1
Product Information
CP 644q
Firestop Collar ,
Product description
■ A ready-to-use firestop collar,made of galvanized steel housing
and intumescent inserts for firestopping large combustible pipes
Product features
■ Ready-to-use collar
■ No construction required 0fir
■ Fast installation time V - V�-
0 Adjustable/moveable fastening tabs Y r
Areas of application �a
■ Sealing of penetrations for combustible pipes from 8"to 10"in • w
diameter
■ Vented or closed pipe
T66t nicaI pata��
® PVC or CPVC pipe Pipe Collar collar No.of
outside outside Height hooks and
For use With Description dia(in.) dia.(in.) _ (in.) fasteners
■ Concrete,masonry,and gypsum walls CP 644-200/8" 8.8 10.0 6.9 10
■ Wall and floor assemblies rated up to 2 hours CP 644-250/10" 10.8 12.4 9.1 12
Temperature resistance -40OF to 140OF(-40oC to 60oC)
Types Of installation Intumescent Activation Approx.392°F(200eC)
■ Wall:two collars,one on each side Expansion ratio(unrestricted) Up to 1:10
■ Floor:one collar on underside(bottom) Approvals
Examples •California State Fire Marshal-No:1185-1200:128
p No:4485-1200:128
® Waste water pipes •City of New York-MEA 631-06-M
■ Fresh water pipes Tested in accordance with
•UL 1479 . •ASTM E 814
paO IN THROUGH-PENETRATION
P DEVICE
- - °� o FOR USE INTHROUGH-PENETRATION" -
FIRESTOP SYSTEMS
L USSEE UL FIRE RESISTANCE DIRECTORY
SN76
Installation instructions for CP 644
Notice Application of firestop system 5. Fastening the CP 644 Firestop Collar.Only when
• Before handling,read Material Safety Data Sheet and 2. Seal the opening.Gaps must be closed with FS- fastened properly can CP 644 offer protection
product label for safe usage and health information. - ONE.The approved methods vary and are given in. against fire passing through.
• Instructions below are general guidelines-always the specific UL system. a.Mark the fastening points.
refer to the applicable drawing in the UL Fire 3;Close the CP 644 Firestop Collar.Place the CP 644 b.Drill holes with a Hilti rotary hammer drill
• Resistance Directory or Hilti Firestop Systems Guide Firestop Collar around the plastic pipe and lock the (i.e.TE 4-A18)or,depending on base material,
for complete installation information closure by applying firm pressure until it latches. fasten using Hilt!powder-actuated tool.
Opening 4.-Attach fastening hooks.The fastening hooks can c.To secure the CP 644 Firestop Collar,use Hilti
be attached to various points on the metal housing.1. Clean the plastic pipes.Expansion of the � 9• anchors fasteners.
intumescent material duringa fire acts to close the This allows the fastening points to be made to suit
d.For maintenance reasons,a penetration can be
plastic pipe.Very dirty pipes,(!a:with remains of, the space available In each case.
permanently marked with an identification plate
mortar)may lead to a delay in this closing action. The hooks must be positioned as symmetrically as and fastened in a visible position next to the seal.
Soiled plastic pipes should,therefore,be cleaned in possible.The required number of fastening hooks Is
the area where the CP 644 Firestop Collar is to be indicated on the packaging. Not for use
installed With metal pipes
• In highly corrosive surroundings
rr E; P t With unapproved anchors/fasteners
Storage
Store only in the original packaging in a location
o
protected from moisture.
1.Clean plastic pipe 2.Close remaining gap to _3.Close collar _ 4.Attach fastening hooks S.Fasten collar and -
provide smoke and gas - Identification plate.Of -
resistant seal required) -
Hilt!Firestop
Saving Lives
® through innovation
and education
Hilti. Outperform. Outlast.
HIM,Inc.(U.S.)1-800-879-8000•www.us.hilti.com en espanol 1-800-879-5000•Hitt!Firestop Systems Guide
MSDS No.: 301
Revision No.: 001
Revision Date: 02/28/05
Page: 1 of 2
a MATERIAL SAFETY DATA SHEETS ,
Product name: CP 643N Firestop Collar/CP 644 Firestop Collar
Description: Galvanized metal housing containing black polymer-bonded intumescent firestop material
Supplier: Hilti, Inc. P.O. Box 21148,Tulsa, OK 74121
Emergency#(Chem-Trec.): 1 800 424 9300(USA, PR,Virgin Islands, Canada); 001 703 527 3887(other countries)
INGREDIENTS'AND'EXPOS,URE LIMITS
Not applicable. This product is considered to be an "article" as defined in the federal OSHA Hazard Communication Standard
29 CFR 19110.1200/1926,59.
a ` a PHYSICAL'DATA"w p, wwk°'h r e.R
Appearance � Metal collar/black firestop Odor t' x None
� 7
. material x „
f Vapor,Density: (air.=1) Not applicable Vapor Pressure t! Not applicable
Boilin 'Point: Not a licable V p' 7.6 /I
9 _ PP OC Content , g±
Evaporation,,Ratei Not applicable Solubility in Waterf ki, Not determined
Specific Gravity: Not determined pH: Not applicable
`- AND
EXPLOSION HAZARD!DATA
s�n - '
� r
Flash Point: z y- Not applicable Flam°mable'Llmits: Not applicable
Extinguishing Media: Use extinguishing media appropriate for surrounding fire.
$peciafFire'Fightmg �� None known.,
Procedures
'UnusuMFire and'Explos on None known. Product serves as a Firestop; intumescent material.inside the collar expands
Hazards. when exposed to temperatures> 1600 C/3200 F..
1 wa EAw ,;
' ;R CfIVITYDATA
Stability Stable. Hazardous Polymerization Will not occur.' -
Incompatibility: 'a, ' 1.
None known Decomposition Products _. None known
Conditions towAvoEd:_ " None known
777 a .
- ,-� HEALTH�HAZAARD DATA
as+». JN,
-Known Hazards' ,;' ` None known
T. Routes f Exposure None known
- �
Signs and Symptoms of 1, None expected from routine use/installation according to manufacturer's specifications and
Exposure -_ y�° technical guides.
Carcinogenicity ` No ingredients are classified as a carcinogen by IARC, NTP or OSHA.
Medical Conditions ''�.' ", None known .
Aggravated_by Exposure- `k
. .w�rr ,. ;':A^; ` #w - 1 ,LTa Up ¢..z+s.•w+ g..,r Y Ab "% y �• x:..
„ EMERGENCY AND FIRST AID,PROCEDURESr'
Eyes 5„x; v . • 4 immediately flush with plenty of water.. Call a physician if symptoms occur.. y'
. .
•Swn Not applicable. Practice good, hygiene; i.e. wash hands during breaks, before eating or
f smoking, and after work.
`Inhalation: . Not applicable.
Ingestion. Not a potential route of exposure
Other - Referral to a physician is recommended if there is any question about the seriousness of any
injury/exposure.
HILTI 0 is a registered trademark of Hilti Corp.
CONTROLMEASURES AND PERSONAL PROTECTIVE EQUIPMENT
Ventilation: General(natural or mechanically induced fresh air movements).
Eye Protection: Not required, however,safety glasses should be worn in most industrial settings.
Skin Protection: ,ii None required; however,(cotton)gloves recommended.
Respiratory Protection: - f No respiratory protection is needed for normal application of this product.
PRECAUTIONSAFE HANDLING AND USE ' „
g .
Handling andStormg Store in a cool dry area. Follow installation instructions.
Precautions:
SpiII Procedures No special requirements.
X :REGULATORY INFORMATION t b
n u-
HazardCommunication: This product is considered to be an "article" as defined in the federal OSHA Hazard
Communication Standard.
DOT Shipping Name:. Not regulated.
IATA/ICAO Shipping Name:'.x Not regulated.
TSCAlnventory Status:, r Chemical components listed on TSCA inventory.
SARA Title 111,Section 313: This product is classified as an "article" and is not subject to reporting under Section 313 of
:1 SARA Title III (40 CFR Part 372).
EPA,Waste Code(s) Not regulated by EPA as a hazardous waste
Waste Disposal Methods Consult with regulatory agencies or your corporate personnel for disposal methods that
comply with local, state, and federal safety, health and environmental regulations.
y
I ` ; � .;� ,�
•� � _ $�wCONTACTS �
Customer Service 1 800 879 8000Tectinical Serv1ce., `"& 1 800 879 8000
Health TSafety: 1 800 879 6000 Jerry Metcalf (x6704)
_Emergency#(Chem Trec)' 1 800 424 9300(USA, PR,Virgin Islands, Canada); 001 703 527 3887(other countries)
The information and recommendations contained herein are based upon data believed to be correct; however, no guarantee or
warranty of any kind expressed or implied is made with respect to the information provided.
MSDS 301, Page 2 of 2
Certificateof Compliance
Certificate Number 20069214-R15431 Page 1 of 1
Report Reference 2006 February 14 Issue Date 2006 February 14 Underwriters
U® L Laboratories Inc.,Wl
Issued to: H i lti, Inc.
5400 S 122ND East Ave
Tulsa,OK 74146 USA
This is to certify that F11'eStop Devices
representative samples of CP643N 50/1.5 in.,CP643N 63/2 in.,CP643N 90/3 in. and CP643N
110/4 in., CP643N 160/6 in.,CP644 200/8 in. and CP644 250/10 in.
Have been investigated by Underwriters Laboratories Inc.®in
accordance with the Standard(s) indicated on this Certificate.
Standard(s)for Safety ANSVUL 1479,CAN/ULC-S 115-05
Additional Information: CP 643N and CP 644 Firestop Collar for use in Through-Penetration Firestop
Systems as currently described in the UL Fire Resistance Directory.
Only those products bearing the UL Classification Mark should be considered as being
covered by UL's Classification and Follow-Up Service.
The UL Classification Mark includes: UL in a circle symbol: with the word
"CLASSIFIED" (as shown); a control number (may be alphanumeric) assigned by UL; a
statement to indicate the extent of UL's evaluation of the product;and, the product category
name(product identity)as indicated in the appropriate UL Directory.
Look for the UL Classification Mark on the product
Issued
Reviewed b y
Mona Cou outl e� Christoph J son
Underwriters Laboratories Inc. Underwrite oratories Inca
IIW fi MSDS No.: 301
Revision No.: 001
MLI Revision Date: 02/28/05
® Page: 1 of 2
MATERIAL SAFETY DATA SHEET:
Product rame: CP 643N Firestop Collar/CP 644 Firestop Collar
Description: Galvanized metal housing containing black polymer-bonded intumescent firestop material
Supplier: Hilti, Inc. P.O. Box 21148,Tulsa,OK 74121
Emergency#(Chem-Trec.): 1 800 424 9300(USA;PR,Virgin Islands,Canada);001 703 527 3887(other countries)
._
INGREDIENTS AND EXPOSURE
Not applicable.This product is considered to be an"article"as defined in the federal OSHA Hazard Communication Standard 29 CFR
1910.120C/1926.59.
PHYSICAL DATA
Appearance: - Metal collar/blade firestop None
material
- t " 'rd�r�k"; "
j Vapor Density: (air-�1) Not applicable Vapor Pressure Not applicable
Boiling'Pcint: $ Not applicable VOC Content 7.6 g/I
Evaporation Rate. Not applicable Solubility A Not determined
Specific Gravity: Not determined Not applicable
ss" FIRE AND EXPLOSION HAZARD DATA777777
n
Flash Poirt: �` Not applicable Flaminabte Lmits�" " � Not applicable
— -
Extinguish ing Media: h E Use extinguishing media appropriate for surrounding fire.
I;Special Fire Fighting¢ None known.
Procedures:
Unusual Fire and Explosion None known. Product serves as a Firestop; intumescent material inside the collar expands when
Hazards: exposed to temperatures>1600 C 13200 F.
77777
REACTIVITY DATA^ � �
Stability. Stable. Hazardous Polymenzation t Will not occur.
E Incompatibility: None known Decomposition Productsf None known
.onditions to Avoid None known
, ,w
HEALTH HAZARD DATAm
.;_ ,_. •k, ,..� � ��- ..�� d �� '�� � �"�.°�
Known Hazards: �� 1 None known Routes of�Exposure_ None known.
Signs and Symptoms of None expected from routine use/installation accordingto manufacturer's specifications and
Exposure:� p
jr�s�, technical guides.
3Carcinoger�icity: 1 No ingredients are classified as a carcinogen by IARC, NTP or OSHA.
Medical Conditions None known
Aggravated bV Exposure
a .EMERGENCY'dNDFIRSTAIDPROCEDURES 'm -�
_ ko
Eyes: Immediately flush with plenty of water. Call a physician if symptoms occur.
Skin. . ..I .Not applicable. Practice good hygiene; i.e.wash hands during breaks, before eating or smoking,
and after work.
--Inhalation: Not applicable.
Ingestion _ Not a potential route of exposure
=Other: Referral to a physician is recommended if there is an question about the seriousness of n' Y Y � any
injury/exposure.
HILTI 8 is a registered trademark of Hilti Corp.
r
CONTROL-MEASURES AND PERSONAL PROTECTIVE EQUIP N _
w
,x
Ventilation: General(natural or mechanically induced fresh air movements).
4
Eye Protection: Not required,however,safety glasses should be wom in most industrial settings.
Skin Protection:
-: required;
protection � le recommended._Respirator No respiratory sneeded fonoalapplication of this prod
uct.
PRECAUTIONS FOR SAFE HANDLING AND USE. N •£
Handling and Storing Store in a cool dry area. Follow installation instructions,
Precautions:
Spill Procedures No special requirements.
h
,7 'REGULATORY INFORMATION !7,T7
Hazard Communication: This product is considered to be an "article" as defined in the federal OSHA Hazard
{ 1 Communication Standard.
DOT Shipping Name: Not regulated.
IATA/ICAO Shipping Name Not regulated.
TSCA Inventory Status:, . ,' Chemical components listed on TSCA inventory.
SARA Title III,Section 313 This product is classified as an"article"and is not subject to reporting under Section 313 of SARA
, Title III(40 CFR Part 372).
EPA Waste Code(s) r" Not regulated by EPA as a hazardous waste
Waste Disposal'Methods Consult with regulatory agencies or your corporate personnel for disposal methods that comply
with local,state,and federal safety,health and environmental regulations.
t. ,CONTACTS L
a
Customer Service 1 800 879 8000 Technical Servldi .' 1 800 879 8000
Health/Safety 1 800 879 6000: Jerry Metcalf (x6704)
Emergency#,(Chem Trec);` 1 800 424 9300(USA,PR,Virgin,Islands,Canada); 001 703 527 3887(other countries)
The information and recommendations contained herein are based upon data believed to be correct; however, no guarantee or
warranty of any kind expressed or implied is made with respect to the information provided:
i
MSDS 301, Page 2 of 2
August 5, 2009
To Whom It May Concern:
Re: The CP 643N/644 Firestop Collars — LEEDs Info.
The Hilti CP 643N/644 Firestop Collars are manufacturered in Italy.
The Hilti CP 643N/644 Firestop Collars have a VOC content of 7.6 grams/liter..
The amount of post-consumer or post-industrial content in CP 643N/644 Firestop Collars is not
known. The metal portions of the collars are recyclable. ,The CP 643N/644 Firestop Collars do
not contain any Rapidly Renewable Materials.
The CP 643N/644 Firestop Collars are not regulated as a hazardous waste by the Federal EPA
Standards. The regulations for the disposal of non-regulated industrial waste can vary from state
to state and even city to city. For this reason, you should consult your local and state regulatory
agencies for direction on disposal.
Please feel free to contact me at (918) 872-3704 if you have questions.
Sincerely.
Jerry Metcalf MPH, CHMM
Safety/Environmental Manager
Hilti Inc.
(918) 872 3704
jerry.metcalf ,hilti.com
Rev. Date: 8/5/09
HIM, Inc.
5400 South 122n'East Avenue
Tulsa, OK 74146
1-800-879-8000
www.hilti.com
CALIFORNIA DEPARTMENT OF FORESTRY&FIRE PROTECTION -"
OFFICE OF THE STATE FIRE MARSHAL
FIRE ENGINEERING-BUILDING MATERIALS LISTING PROGRAM
LISTING SERVICE
LISTING No. 4485-1200:0128 Page 1 of 1
CATEGORY: 4485--OPENING PROTECTION(FIRESTOPPING)
LISTEE: HILTI, INC.5400 S 122nd East Ave.,Tulsa,OK 74146
Contact:Clay Hensley(918)252-6216 Fax(918)254-1679
Email:clay.hensley@hiliti.com
DESIGN: Type CP644(may include a size designation between"643"and"N")Cast-IN Firestop
Devices for use in through penetration systems. Refer to listee's data sheet for detailed
product description and operational considerations.
INSTALLATION: In accordance with listee's printed installation instructions, UL Fire Resistance Directory,
applicable codes&ordinances and in a manner acceptable to the authority having
jurisdiction.
MARKING: Listee's name,model number, classification and UL label.
APPROVAL: Listed as collar firestop device for use in through penetration system when constructed and
installed in accordance with UL Fire Resistance Directory.Approved systems:C-AJ-2109,
W-L-2078.
�6Ty o' This listing is based upon technical data submitted by the applicant. CSFM Fire Engineering staff has reviewed
the test results and/or other data but does not make an independent verification of any claims. This listing is not
®� an endorsement or recommendation of the item listed. This listing should not be used to verify correct
operational requirements or installation criteria. Refer to listee's data sheet,installation instructions and/or other,
Date Issued: July 01, 2011 Listing Expires June 30,2012
Authorized By: FRANCIS MATEO, Program Coordinator
Fire Engineering Division
Y
CALIFORNIA DEPARTMENT OF FORESTRY&FIRE PROTECTION
OFFICE OF THE STATE FIRE MARSHAL
FIRE ENGINEERING-BUILDING MATERIALS LISTING PROGRAM
LISTING SERVICE
LISTING No. 4485-1200:0131 -Page 1 of 1
CATEGORY: 4485--OPENING PROTECTION(FIRESTOPPING)
LISTEE: HILTI, INC.5400 S 122nd East Ave.,Tulsa,OK 74146
Contact:Clay Hensley(918)252-6216 Fax(918)254-1679 .
Email:clay.hensley@hiliti.com
DESIGN: Type CP643N(may include a size designation between"643"and"N")Collar Firestop
Devices for use in through penetration systems. Refer to listee's data sheet for detailed
product description and operational considerations.
INSTALLATION: In accordance with listee's printed installation instructions, UL Fire Resistance Directory,
applicable codes&ordinances and in a manner acceptable to the authority having
jurisdiction.
MARKING: Listee's name,model number, classification and UL label.
APPROVAL: Listed as collar firestop device for use in through penetration system when constructed and
installed in accordance with UL Fire Resistance Directory.Approved systems: C-AJ-2109,
W-L-2078,W-L-2084.
54NQ" This listing is based upon technical data submitted by the applicant. CSFM Fire Engineering staff has reviewed
the test results and/or other data but does not make an lindependent verification of any claims. This listing is not
an endorsement or recommendation of the item listed. This listing should not be used to verify correct
operational requirements or installation criteria. Refer to listee's data sheet,installation instructions and/or other
Date Issued: July 01, 2011 Listing Expires June 30,2012
Authorized By: FRANCIS MATEO, Program Coordinator
Fire Engineering Division
i
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i ZONM SUMMARY
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WN. FRONT SETBACK 20'
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S14'14' MAIL WILDING HEIGHT 40'
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