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527 CMR 1.00
Section 1.12.8.2.1
Apptication for pe.rru. a"*lrorllelificate orcompletion for the
Installation or Alteration ofFucl Oil Buming Equipment and the Storage ofFuel Oil
FP-056
(Rev. 1.26.2015)
Permit #'s: FD lnLfil
Owner/Occupanl Name:
lnstallation Address:L4L .$ Rl
3
Elec FDID#
ity or Town)(Date)
Serviced Floor or Unit #:
Other
Fee Paid: $rtf *tr0t{,
Tel.#4 ?
Heating Unit
Burner: New
Domestic Water Heater
Existing Location
Type:Model # or Size
Waste Oil Removal
o,-.L
Twe p /)L t/1/l Capacity:2 ).f salons
Special requirements (or additional safety devices)
No. of Tanks: /
OSV valve 26it un Protected
Co. Name: 1, ,"{ F^./ret# 576 4 6s'z e
Address q (^ Tl." n., O,l:+J,,9 cny: E E1/..<.o q7\zip d 2-r3 6
Completion Date:
Combustion Test:
t?-,1 -t I
Gross Stack Temp
CO, Test:
Net Stack Temp
Breech Draft:
Smoke: _Overfire Draft Efliciency Rating %
ersigned cerlify that the installation of fuel buming equrpment has been made in accordance with M.G.L. Chapter 148 and 527 CMR 1.OO
in effect. Fu.thermore, this installation has been tested in accordance with such requirements. is now in proper op€rating condition andinstructions as to its use and maintenance have been fumished to the person or whom the installation (or al ) was made
1
l, the und
cunontly
complete
lnstaller:t.
Narne Cetl of C#
Address 9t1 n-f zs ,'*, "L
Once signed by the fire d
City:
. this is a PE for lhe storage of fuel oil and use of the oil bumirE equiprnent
Date
t Stamp)
Power Vent
Mfg:
Nozzle size:
Fuel Oil Kerosene
^aStorage Tank: I/New Existing Location:
Approved by:
Keep original as application. lssue duplicate as permit. This form may be photocopied.