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Permir #'s: FD Et--
Owner/Occupant
[n5trll43iqn
EJ Heating Unir E oomcstic wucr-
Bumcr: E Ncw E gxistiag
Trade Name:
(Gry or Town)
FDID#:
afiz Comnorrutu{tfr. of Tr{oss arfuset*
Deporana* of e"6ti" Safrtg
527 CMR 4.00
Form I
Application for Permil Permit, and Certificate of mmpletion foi the Insrallarion or
Alteration of Fuel Oil Burning Equipment and the Storage of Fuet Oil
4c Tcl *i 566-775- 't4 L\/
ewiced Floor or Unit * z
cnt E orhcr
Locarion:
Mfg:
t ScH,-,1 Model # or Size:Jzs -----e4sila-r,.ocauon: lTztfP'arr-"--rf
ts Fuci oil E Kcroscne E $i/asc oil k't
Storage Tanb E Xew tr fxkting Location:
TyPe
Type:
Ot D6u.raa t ,.<-.*<
5P)(>
4tT 5 Capaciry:gais. No. of Tanks:
E Osv valre ,{ru^"protecred E Shcct Rock E Sprin}lcr AFUE: E ycs E oo
Combusoon Tcsc Nozde Sizc Gross Suck Tenrp.:
Brccch DrafcNew Suck Tcmp.: CO lTesr
Smoke:Ovcrfirc Drafi:
I, rhe unclersign€d certify rhat rhe insralladon of fuel buming equipment has been made in accordance {,ith M.C.L. c. 148 and 527 CMR 4.00
.o.rcntly m .ft..t. Funhermore, this installation hrs beeo tesred in accordancc with such requiremetts, is now in pmpcr operating condkion and
complete instructions as to its use and rnaintenance have been fumished to thc person for whom the installation (or elt€ration) uras made.
Co. Name
Addres
lnstaller:
lnspected by:
(/
zip:7ltVCity:J).UeN/l )
Pnnr Narrllr Sigfladre (no
torOnce signed by the fire dePartmeT( this is a PERMIT the storage and use of6i[ buming equipmenr.
C
I
o71t\Date:
Q71A tt,
@ate)
Fee Paid:
)/ /o
Speciai requiremcns (or additional sdery &vices)
Efficicnry radng 70:
I
T"l. = --= -_-(
)
er 6^
wHtlE COPY: Pmperty orvne/s copy; CANARYCOPY: YF.D. Copy'Return wheniob b completedi PINKCOPY'Thls copy mult be posted at instsllstion'