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527 CMR 1.00
Section 1.12.8.2.1
Form 1
Application for Permit, Permit, and Certificate of Complerion for the
Installaaion or Alteration of Fuel Oil Buming Equipment and the Storage of Fuel Oil
S. ta"-,-.,-lh q/aul*
(City or Town) (Date)
-Fe€ Paid: , 5A -Permit #'s: FD
Owner/Occupant Name E[r
/6 ft*tn.; R
FP-055
(Rev. 1 .26.2015)
lnstallati0n Address:
- Heating Unit
Bumer: New
lr4fg:
Elec. _FD ID#
Domestic Water Heater
DGxisting - Location
Tel.#fos - 39u - S&Lo
Power Vent Other
:t-,r-..-i {-
Type:
(,fuer oit
Storage Tank:
Type:A Capacity
Special requirements (or additional safety devices)
RemovalKerosene
isung Location
\L# g"nont No. of Tanks
OSV valve
Co. Name:
&,, ,,n. Protected
iIJL
*rar"t",435 (r ivt
Completion Date:
Combustion Test:
City 5' Duv,"t,
Gross Stack TemP
CO'? Test:
Net Stack Temp
Breech Draft:
Smoke Overfire Draft:
that th€ installation
Efflciency Rating %:
I, thc undeGigned c4rtify of fuel buming equipment has been made rn accordance wth
cunently in effect Fu.the.more,this installation has been lested in a@ordance with such requ
complete insti,rclions as to its use and maintenance have been fumished lo the Person or whom th
lnslallen b.t-=t ?
14E and 527 CMR 1.00
gperating cgndition and
alteraiion) was made
Ceft af C#
Address:3€ f,-ft3 Bo o
Once signed by the fire dcpartnent, this is a PERMIT for the stor-age offuel oil and use of the oil buming equipment
Date
cfty or-fl't
Sionatue ho Slamo)
Ta,r>u,,
Approved by:
Ke€p original as application. lssue duplicate as permit. This form may be photocopied
Serviced Floor or Unit #:
Model # or Size:Nozzle size:
r",#.5o8-3:8-383 I
zip: OLLGO
Waste Oil
in