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APPLICATION FOR PERMIT
City or Town:
Date:!7 / Os /2Ot2
permit Number: '101185
ln accordance with the provisions of M.G.L. Chapter 148, as provided in Section 10 A application is hereby made
by:
Address: 82 Baker Rd /West Yarmouth, MA 02673
For permission to: lnstall Oil Burning EquipmenUtanks
Name of Competent Ope rator: ef winslow pi 39+7778 Cert. No
Date lssued-Rejecled lL / OS / 2OL2
Date of Expiration: L2/05/2012
(Signature of applicant)
Due
By
THEUOl
BAKEOT
Fee: Sso.00 $ paid
Yarmouth
,4,
I;P-056
(Rev.04/10)
Permit #'s: FD o
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527 CMR 4.00 Form 1
Application for Permit, Permi! and Certificate of Completion for the
Installation or Alteration of Fuel Oil Buming Equipment and the Storage of Fuel Oil
(Cily or Town)
FDID#oar6l Fee Paid: $
rer.#: fO& 154-q 7)4
I Domestic Water Heater
ll Existing E Location
Serviced Floor or Unit #
Other
C-trJ Model # or Size Nozzle size
E Kerosene E Waste Oil
te)
lnstallation Address
l{Heating Unit
Burner:
Mfg:
Type
frFuel Oil
Storage Tank: D New
E Power Vent
Special requirements (or additional safety devices)
sting Location
capacity: )? fgattons
W-,
Co Name
Address
Completion Date:
Combustion Test:
#b,' ainu Protected E Sheet Rock E Sprinkter AFUE: [)?ryes E no
(furnace\and boilers)
a Tel #
EF: fJ yes El no
(water heater)
City
>-
Gross Stack Temp
CO'?Test: I
Net Stack Temp
Breech Draft:
tsn
a
4o
o
ASmoke: U Overfire Draft:Efficiency Rating %
l, the undersigned certify that the installation oftuel burning equipment has been made in accordanc€ with ir.c.L. Chapter 148 and 527 CMR 4.00
currently in
complete in
lnstaller:
effect. Furthermore this installation has been tested in accordance with such operating
as to its use intenance have been furnished to the person the (ol ad
Signature (no Slamp)
Address City
Once signed by the flre department, this is a PERMIT for the sto.age of fuel ojl and use of the oil burning equipment
DateApproved by
Keep original as application. lssue duplicate as permit. This form may be photocopied
Elec.
owner/occupant Nrre, S 161-=A[-xa Fnxae Rrr hr.(4uzofil
No. of Tanks:Type:
[J oSV valve
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