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Applicarion for Permit, Permit, and Certilicate of completion foi rhe Insullarion or
Alteration of Fuel Oil Burning Equi rage of Fuel Oilpment and the Sto
Rn'\Ou-lA qlzt lo s
(Ciry or Town)
FDID#:
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Fee Paid: i Zc'Permir *'s: FD _ Bcc._rt
Owncr/Occupant Name:
ln5ratl4i61 Addrcss:
El Headng Unit
Bumer: Ei New
Trade Name:
oiltr
New Stack Tcrnp.: CO
Smoke:
('
ICI F:
Serviced Floor or Unir *
-El Domesdc warcr Heacr El Powcr vcnr E othcr
d g"ir,iog [ocation:
Mfg:
Model # or Size:Locadon:
E Wasc oil
EI Existing Location:OUBb6Storage Tanl:New
rw", MBcb UtW( capaciry: ?,-" gais. No. of ranls:
Special requiremens (or additional safery dcvices).IouDte, Vlttr-r40K
0o
E osv valvc Oil linc protccted E Shect Rock E Sprinklcr AFUE: E ycs E Io
Combusrion Tesc Nozzle Sizc Gross Stack Tcrnp.:
;Tcsr
Efficienry rati.ng 9o:
I, the undersigned ceniS that the installarion of fuel buming equipment has been made in accordance with M,G.L. c. 148 and 527 CMR 4.00
cu.rently in effect. Futhermore, this installation has heen tested in accordance with such requirements, is nou, in proper operating coodition and
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Address n4tat zip oar!City:
Installer:-Ttr/
Pana Name Sr'giafir. (no SBrnp)
Once signed by the fire department, this is a PERMIT for the storage and use of oil bumrng equlpment
lnspected by:/-* 77e.t
222
,4-<Date:2 6
lfie C omnonut eattfr. of grtass acfus ets
Deporanatt of t"6ti" S"f"tl
527 CMR 4.00
Form I
Breech Drafc
Ovcrfire Drafc
have been fumished to the pcrson for whom the installation (or alteration) was made.
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WHm COpy: property owne/s copy; CANAf,Y CoPY: Y.F.D. Copy. Betum when iob h completedi PINK COPY-This copy mustbe posted al installation.