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tfrz Conanonanoltfr. of fl{assaiuse*s
Depottnw* of 9"6fu Sof"ty
527 CMR 4.00
Form I
Application for Permit, Permit, and Certificate of completion for the Inslrllation or
A.lteration of Fud Oil Burning Equipment and the Storage of Fuel Oil
(Gry or Town)(Darc)
Fcc Paid:Permit #'s: FD FDID#:
Owncr/Occupant Namc:
lnsullationAd&css: ft M Scrviced Floor or Unit f
-EI Hcrring Unit E Domestic Warcr Hcarcr EI Power vcnt E Other
-
,6.
Bumcr: fi New E gxisting Location:
Trade Name: .Mfg:
il/rt,
ftftr,
Type:
Type:
//rr Locarion:o(//Modcl # or Sizc:
E-fucl Oil E Kcroscnc EI Wasrc oil
Storage Tank E New W F-x;s*g, Location:
,t/4/ /5rrl (Capaciry:.) 7,gals. No. of Tanls:
Special requiremcns (or additional safery &vices)
E osv valve {or*rprorccred
Combustion Tcsc Nozrlc Sizc ' t, f
E Sheet Rock E Sprinklcr *ln dit E no
Gross Stack Tcrnp.:3Zo v
New Suck Tcrnp.: COrTcsr //,7
Smokc
Address
Overfire Drafc --0/
(
Efficiancy rating 9o:
l, the undersigned ceni& that the installation of fuel buming equipment has been made in accordance with M.C.L. c. 148 and 527 CMR 4.00
cu ently in effect. Furrhermor€, this installatioo has becn tested in accordance with such requircments, ii now in p.oper operating condition and
complere insrnrctions as to its use and rnaintenance have been frunished to the person for whom the installation (or alteration) was made.
Co. Name Tel. +8-z
,J) re/tGttft, /t//,(/City:t*?w Zip: i?-c6 a
Installer
Pnn! Nome
Once signed by the fire , this is a PERMIT for the storage
lnspected by:Date
\./ -,F,*"6s^,p,
and use
:
of oil buming equipment.
,//u
WHITE coPY: Property itvmer's copy; OANARY coPY: vF.D, copy - Return when iob b comptetedi plNK copy - Thb copy must be posted 8t install tion
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