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APPLICATION FOR PERMIT
City or Town:
Date:
Yarmouth
05/Lr/2012
permit Number: 10.1061
ln accordance with the provisions of M.G.L. Chapter 148, as provided in Section 10 A application is hereby made
bY: Fred Richards
Address: 6 Akin Av /South Yarmouth, MA 02664
For permission to: lnstall Oil Burning Equipmenutanks
Name of Competent Operator:hall oil p: 398-3831 Cert. No
Date lssued-Rejecled 05 /Ll/ 2Ol2 By
Date of Expiration: O6/tf /2012 Fee: S50 ' 00 $ Paid
THEUOl
AKINOl
(sEnature ot applicant)
Due
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527 CMR 4.00 Form 1
Application for Permit, Permit, and Certificate of Completion for the
hstallation or Aiteration of Fuel Oil Burning Equipment and the Storage of Fuel Oil
(City or Town)
FP-056
(Rev.04/10)
Permit #'si
Owner/Occup
Cp&;
FD \O\nb\ Er
"nt Nur", ffi-l OJ*Ar 8l- 6 l-{7[oec
(Date)
Fee Paid: $roro*, C[3\Rl
f el.#:7
lnstallation Address
y'HeatingUnit
au^"r, ffin
El Power Vent
t'i,,1
Mfg:
Type C".--
-fi4^
Special requirements (or additional safety devices)
Model # or Size €> -/Nozzle size: 7S-b"/
E Waste Oil
p€xisting Location
Capacity: ?7 S'-galtons No. of Tanks:
.zkFueloil
Storage Tank: E] New
fl Kerosene
E oSV vatve 6r rrn"Protected E Sheet Rock E Sprinkler AFUE: fl yes E no EF: E yes E no
(lurnace and boilers) (water heater)
3 < -383
Zip 0>blo
Co. Name
Address:+35 /)Y _tCity:
I -/a -/ 1-Completion Date:
Combustion Test:Gross Stack Temp s'ao
CO'?Test: / > /,
instructionsas to its use and mai
.,_-J qr.rl.a,
21. Lerr-rna-
have be6n furnished to the porson or whom the installation (or a
oEo)L--
/{zNet Stack Temp.:
Breech Draft:--.tY
Smoke overfire Draft - -O l"'AL
I, the undersigned c€rtify that the installation of fuel burning aquipment has bsen made in accordance with M.G.L. Chapter 148 and 527 CMR 4.OO
currently in etlecl Furth6rmore, this installation has been tesled in accordance with suctr requirements is now in propsr ating cond
complete
lnstaller
Addressl
(noCetl of Cl
Cjty
Once signed by lhe fire padment, this is MIT fo. the storage of fuel oil and use of lhe oil burning equipment.
Dale
Keep original as applicati lssue duplicate as permit. This form may be p copied
b AY;,"^ Lvt
E Domestic Water Heater
E Existing E Location:
Serviced Floor or Unil #:
Other .
Type:
Tel #&4;
Efficiency Rating %:
{-Approved by:Z-