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527 CMR 1.00
Section 1.12.8.2.1
Form 1FP-O56
(Rev. 1 .26.2015)
Permit #s: FD
Owner/OccuPant Name fl.o t u'8
Application for Permit, Permit' and Cenificate of Completion for the
Iostallation or Alte.ation of ftlet 6iiB;i"g equiptem and the Storage of Fuel Oil
glt [2c*-t-
(City or Town)(Oate) _,- r,z.-
d.$ boFDID#: --
Tel.#:b t/))t Ct ,q Lc
Serviced Floor or Unit #:rtK,nlnstallatidn Address:
- Heating Unit
Burner New
Mfs ,a
lct {+v-2
Power Vent Other
Domestic Water Heater
D/eri"ting -. Location
t
Waste Oii
Nozzle size
Model # or SizeType
*
Removai
uel Oil Kerosene
E;isting Location
Storage Tank 2(e\!
TyPe
Special requirements (or additional safety devices)
- OSV valve
Co. Name
fu,' atn" Protected
r/-jL
435 tv+City(r
Tel r+B -3ts31
Z\Pt,
Completion Date:
Address
complete
lnstslleI
Address:
-
Combustion Test: Gross Stack TemP'Net Stack TemP
CO'?Test:
.ure.tly i. eftect Furthern
ns use and maintenanceore this installation nes been tested in accoli
have been fumished
ance with such requ
to the pe6on or \ rhom
rns as tc
Smoke: -.- Overfire Draft:
l, the undersigned certify that the installation o, fuel bu.ning equiPment has been made in accordance G.L 148 ano 527 CMR '1 00
foperating condfion and
Pint Name
3€ ftft3 Bo o
PERMTT tor the storage of tuei cil and use o{ the oil bum'ng equiprnent
Efficiency Rating %'
ln
ture (no SfamP)
City A,U {
DaielOoce signed by the fire dePadment this is a
_bt L
Cen of
a,-
KeeP original as aPPlicatron lssue dupiicate as permit This form may be photocopied
r2
lr*. r^o,)L
Capacity:LT5 saton, No'ofranks:
I I oLuL" o
Breech Draft:
Approved bY: