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('^.afrz Comnonano[tft of 1v{ass oc$us et*
Deportnatt ,f p"bfu S"fetg
s27 CMR 4.00
Form I
Application for Permit, Permit, and Certificate of completion foi the Inssllarion or
Alteration of Fuel Oil Burning Equipment and the Storage of Fuet Oil
lll()-lcl Bcc.FDID* O,IPermit #'s: FD
Owncr/Occupant Name:
[n5t: Il4sisn Address:
$Zlcadng Unit
Bumer d(c*
Trade Namq /'
lcl f,
(?Scwiced Floor or Unir f
-E Domcstic Warcr Heacr E Fowcr Vcnr El Orher
E exisag lacarion:
Mfg:
Typc:Modci # or Size:
Q Fucl Oil EI Kcroscnc E Wasc oit
Storage Tanlc E New El,€xisdng Location:
Location: /
..?
Type:Capaciry:gals. No. of Tanks:
E OSv valvc El, Oit tlnc protccred Ek Sh.a Rock E Sprintlcr AFUE: Etr'ycs EI no
Smokc:
Gross Stack Tcnrp.:
New Sack Tcmp,: COrTcsr Brcech DrafcIOvcrfre Drafr Efficienry raring 7o:
l, the undersigned certify that the insrallation of fuel buming equipment has heen made in accordance with M.C.L. c. 148 and 52? CMR 4.00
currently in effect. Furthermore, rhis installation has beeo rested in accordance wirh such requirements, is now in prof,er operating condition and
complete insrructions as to its use and nraintenance have heen furnished trr rhe perxm for whom the installation (or alteration) was made.
Co. Name T.l. .
l/'/4
Addressr
lnstaller
/)a t Lrty z$,
7tq67
Once signed
lnspected by
Prhr Narp
W
t*y7l
this is a PERMIT ror the st
Signarre (no Sramp)
.*r" r"d ):;fi:[ buming equipment
//t ilDate:
WHIE COPY: Prolerty owne/s copy; CANARYCoPY: YF.D. Copy- Betum wi€niob i! completed; PltlKCoPY.nis copy must be posted at installation.
(Gry or Town)(Datc)
Fce Paid:SIv
Ktru /5 e(fteV
6 ota /l u (,
7Jase.,ya.rl
5 kr/)
Special requiremens (or additionai safery &vices)
Combusrion Tcsr Nozz.te Sizc 6{.
n, / .{,s41as$
,)2
77-
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