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527 CMR 1.00
Section 1.12.8.2.1
Form 1
Application for Permit, Permit, and Certificate of Completion for the
Installation or Alteration of Fuel Oil Buming Equipment and the Storage of Fuel Oil
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(City or Town)
FDID#:,""3X,-
FP-056
(Rev.4.2019)
Permit #s: FD
Owner/Occupant Name:
lnstallation Address SB(
Elec. _
\L
D Heating Unit E DoggFtic Water Heater
Bumer: D New Edsting E Location
E Power Vent
Mfg:
Model # or Size:Nozzle size:Type:
E Fuel Oil
Storage Tank:
E Kerosene
E New E existing
El waste oil
oval Location a
Type:3\ ec\Capacity:
-
gallons No. of Tanks:
Sp€cial requirements (or additional safety devices)
E oSV valve
co. Name:
Address:o
Completion Date:
Combustion Test
Smoke:
il Line Protected
as
Gross Stack Temp.
3 City:{
fuY'tl&a -oaqr
02trs)
0 Tel #
CO'?Test
Net Slack Temp.
Breech Draft:
Overfire Draft:Efficiency Rating %
l. the undeEigned csrtify that the installstion ol luel buming equlpment has beenmade in accordanc€ with M-G.L. chapter148 and 527 clVR 1 00
a*""tii" "i"a. Furthermofe, this lnstallation has b€en Gsted in accordance with such roquitsments, Is now ln propor operating condition and
-rpr"i" i"ri.it'rn" "s to its use and malntenance hsvs been fumlshed to the person or whom the installstlon (or alterallon) tYas mads'
lnstalleI Ced of C*Signaturc (no Stamp)
CityAddress:
Kesp original as application. lssue duPlicate as P€rmit. This form may be Photocopied
lr/Paid: $5o-
Serviced Floor or Unit #:
-
l,tthar
Caa
zip:
once stgngd by the fire department, lhis ls a PERMIT for the storage of fuel olland use ofthe oll bumlng equipm€nl
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FP{06
(Rev. 1.2018)
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Application r Standard Permit
I Ratum completed application to:
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Permit Number:
City or Town
Date Af
lna ance with th ptovisicns of M.c
by
L. Chapter 143, as provided in Section rD ,applicadon is hereby madeq
cf 0
for permisslon to
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(AddrEs
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(Phone Number)
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state clea purp which permit is req
e
s: Slreet or P.O. gor.or Towr, Zp de)
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Name of Competeot Operator (ii applicable)cert. Ho. L,r.r - Uoq6
Date lssued-rbjected By
DIG SAFE NUMBER
Start Date:
Date of expiration Fee
(Slgnatur' o, A0pa6r)
Amount Paid $
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FP{06
(R€v. 1..2018)PERMIT
Date
Permit Number (if appliceble)
ln accordancs with u|e provisions of M.G.L. Chapter 148, as proMded in
to
lhis permit is granted
DIG SAFE NUTIIBER
Start Date
(Futr Nems o{ Psrson. Fi.m or Corporaoon)
for
Rastricllons:
at
(S[!ot and f or ocscibc Locatlon lor AdGquato ld€nfifcallon)
Fee Paid 3 This permit will Bxpire on
Signature ot Official Granling Permit:Tltle
+ This permit must be conspicuously posted upon the premises ts
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