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APPLICATION FOR PERMIT
City or Town: Yarmouth
Date:09 / 21 /2016
permit Number: 101969
ln accordance with the provisions of M.G.L. Chapter 148, as provided in Section 10 A application is hereby made
by:
Address: 27 Crab Creek Ln /South Yarmouth, MA 02564
For permission to: lnstallation of oil burner
Name of Competent Operator: John Souza- JSS Corp lnc.
By
Cert. No
Date of Expiration Fee: 950.00 S paid
GEnature of apdiEilf
Due
't 15
27CR01
Date lssued-Rejecled 09/27 /2OL6
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FP-056
(Rev. 1.26.2015)
527 CMR 1.00
Section 1.12.8.2.1
Form 1
Application for Permit, Pcrmit, and Certificate of Completion for the
lnstallation or Alteration ofFuel Oil Buming Equipment and the Storage ofFuel Oil
Permit #'s: FD _Elec
Owner/Occupant Name:tv1 t4/2 l?64"/\)
(City or Town) (Oate)
Feepaid: $ fr,6
Tel.#q -4io84
k_Serviced Floor or Unit #:
Power Vent Other
FDID#
lnstgUdtion Add
dHeating l.)nrr
rESS
Burner:
Domestic Water Heater
Existing Location
Mfg 4s-tar /1-t c/-,aN
isting
Type buN Ivlodel # or Size N6o -3 Nozzle size:
Fuel Oil
Storage Tank: New
Type:7n44
Kerosen Waste Oil
Location B
Removal
Capactty: ?lfgattons No. of Tanks:
Special requirements (or additional safety devices)Tpre -o-tv ot'/
/t-t,
OSV valve
Completion Date
Combustion Test: Gross Stack Temp
CO' Test:
k/
il Line Protected 7fi*z,wrl/;Z<-,tV/-
Efficiency Rating %
rct* ?44.?72-*-t{
Zip olc;/
48 and 527 CN.4R 1.00
condition and
Net Stack Temp.:
Breech Draft:
Smoke: _Overfire Draft
l, the und
currently
complete
lnstaller:
ersigned cerlafy that the installation of fuel burning equipment has been made in accordance with M.G.L. Chapte. 1
in effect. Furthermore. thas installation has been tesled in accordance with such requirements, is now in proper opeinskuctions as to its use and maintenance have been furnished to the person or whom the installati ora rationU2
Cen of C#
Address City:
Once signed by the fire department, this is a PERI/IT for the storage of fuel oil and use of the oit buming equipment
Oate
Signature
Approved by
S e
Ynzr',.ro,77 7 )l-zor^
)"7 ConA
Co. Name:
Address: ,8 br ,'-r1-^ ^6,J 'i ",t!nv, BPar qza<
Keep original as application. lssue duplicate as permit. This form may be photocopied.