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APPLICATION FOR PERM!T
City or Town: Yarmouth
Date:04/06/2022
permit Number: 102984
ln accordance with the provisions ol M.G.L. Chapter 148, as provided in Section 10 A application is hereby made
bv: RocER APPLEBY
Address: 15 APPLEBY ROAD /West Yarmouth, MA 02673
Wt
!.-4!
For permission to: lnstall Oil Burning Equipmenutanks
Name ol Competent Operator APPLEBY/BUSTY'S INC Cert. No.
Date lssued-Rejecled O4 / 05 / 2O22
Date ol Expiration
By
Fee: $50.00 $ paid
(Sr-0natureof applicanif
Due
142
APPLO3
Sr-\V*,-*r,o,no./tl.oy'ay'/*;do./nu.m
'Qro,loorr1"/€7r2o
527 CMR 1.00
Section 1.12.8.2.1
Form 1
Application for Permit, Permit, and Ccnificate of Complction for the
Installation or Alteration ofFuel Oil Burning Equipment and the Storage ofFuel Oil
FP-056
(Rev. 1.26.2015)
Owner/Occupant Name
lnstallation Address:
Permit #'s: FD Elec.
3)1-LItTL
(City or Town) (Date)
Fee Paid: S -50 '' c't''}
rer.#: 7sa - 6111 - D/ b I
t-^ I .5
Serviced Floor or unit#: b
Power Vent Other
Arc W!-V4T
FDID#
oG{m..
t,
Heating Unit Oomestic Water Heater
Burner: v-ttt"* Existing Location
PPL€E
(,
Mfg Outf-:
toit Kerosene
Location
Model # or Size /_x_or - 1
Waste Oil
():fsiD6
Removal
Type
Special requirements (or additional safety devices)
capacity: 27€ gallons No. of Tanks
OSV valve il Line Protected
-Rrt y Grc Tel #Tob'TtS - naj
zip cLb13Address:22?- Mtot-l-.cc V k City \,\)t\tztvtr:
Net Stack Temp
Breech Drafl:
Smoke -4-Overfire Draft
l, the undersigned cerlify that the installation or luel burning equipment has been made in accordance with M.G.L. Chapter 148 and 527 CMR 1.00
curently rn etfect. Furthermore, this installation has been tested rn accordance wth such requirements. is now in paoper operaling condition and
lnstaller E$-fs4
Ced of C#
Address <t {\,-.L T)'-City:
Once Slgneo by the fire department, lhis is a PERMIT Jor the slorage of fuel oil and use of the oil buming equipment.
Date
Keep original as application. lssue duplicate as permit. This form may be photocopied
(no Stamp)
t
Nozzle size:
Storage Tank: New (existlng
Co. Name:
completion oar-: 3 ^ l5 ''Za,ZL
Combustion Test: Gross Stack Temp.:
CO'? Test:
Efficiency Rating %:
complele instructions as to its use and maintenance have been fumished lo the person or whom the installation (or alteration) was made-),--l r
Approved by: