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FP-056
(Rev. 1.26.2015)
Mfg
Type:
DG uel Oil
C4* z-".r/eZ>' Qff*,rr*
527 CMR 1.00
Section 1.12.8.2.1
Form 1
Application for Permit, Permit, and Certificate of Completion for the
lnstallation or Alteration ofFuel Oil Burning Equipment and the Storage ofFuel Oil
Vr*t*rrr**r*lr/a,/b/"n"Ltfr,
cfh Yr".r rno.tL5<t
Permit #'s: FD Elec
Owner/Occupant Name Mik (',
tl
FDID#
(City or Town)(Date)
Fee Paid: S
Tel.#:O -)5
q kt k Serviced Floor or Unit #:
**,?-'^^
Domestic Water Heater
sting , Location
Power Vent Other
wvr t-.2-\ {-
Kerosene
Model # or Size
Waste Oil Removal
Storage Tank N isting Location
Type:\rl
Special requirements (or additional safety devices)
OSV valve
Co. Name:liJL.
nadress:435 (r tv+City:(zvLli
Completion Date
Combustion Test: Gross Stack TemP
CO' Test:
Net Stack TemP
Breech Draft
Smoke: _ Overfire Draft:Efflciency Rating %
l, the undersig ned certify that the installation of tuel buming equlpment has been made rn accordance \ /ith
[Q,, a,n" Protected
cunently in effect.Furthermo.e, this installation has been tested in accordance with such requirem
Tel #B-3ts31
Zip:GGO
pter 148 and 527 C[/tR 1.00
per operating condition and
alteration) was made
aturc (no Stamq)
tn
complete lnstruclions as to its use and maintenance have been fumished to the Person or whom
lnstaller:AJ -b 1a
Pint Name Ceft ot d
Adoress ?€ f-ft3 Eo Crty oufl{
oncesignedbythefiredepartnent.thisisaPERM|TforthestorageoffueloilandUseoftheoilbum.ngequipmenl
DaIeApproved by
Keep original as application. lssue duplicate as permit This icrm may be p
t?
lnstallatidn Address:
- Heating Unit
Burner: New
Nozzle size:
^ --./Capacity: J-12 gattons No. of Tanks:
5,