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APPLICATION FOR PERMIT
City or Town:
Oate:
Yarmouth
12/22/2014
permit Number: 10159S
ln accordance with the provisions of M.G.L. Chapter 148, as provided in Section 1O A application is hereby made
by:
Address: 93 Baker Rd Mlest Yarmouth, MA 02673
For permission to: lnstall Oil Burning Equipmenutanks
Name of Competent Operator Fuel Co ph.: 508-548-3030 Cert. No.
Date lssued-Rejecled 12/ 22/ 20L4 By
(Signature of applrcant)
Date of Expiration 03 / 23 / 20L5 $ Paid
-
Fee: 550.00
THEUOl
BAKEO6
Due
tfrz Comnonaruttfi of grh,ssacfuse*s
Depornrmt of eubti" Ssfety
527 CMR 4.00
Form I
Application for Permit Permit, and Certilicate of completion for the Insullarion or
./", ,/,
"(Gry or Town)@atc)
rel'rut = s: l.u Elcc.FDID#:Fcc Paid:
./
A..
Owner/Occupant Narnc:Tcl tl:?ot- Ql/- ?t/l
fu5rell4i6n Address:3
fl nearing Unir
Bumcr: ,EI Ncw
Trade Name:8..,L.+l
Type:C-
E Domcstic Warcr Hearcr E] Power Venr
E gxlsting l.ocation:Bno,
Serviced Floor or Unit *
-E oIhcr
,4""l
Mfg:4 r*. .9,.Lr+
Model # or Sizq llfC Locarion:
! Fuel Oit E Kcmscnc E Wastc oil
Sorage Tank E Neo, S edtti"g Losation:
Tlpe:.rQ"tL Capacity:4zr gals. No. of Tanks:
Spcciai requiremcns (or additional safcry dcvices)
EI Osv vaive E Ou un. protecred E Shect Rock E Sprintlcr ertlE: 6 yes El no
Combustion Tcsc Nozzle Sizc Gross Stack Tcnrp.:
Brcech DrafcNew Suck Tcmp-:
Smoke:
CO lTcst
Efficicncy taing 9o:
I, rhe unde*igned cenify rhar rhc installation (f fuel huming equipment has been madc in accordance with M.G.L. c. 148 and 527 CMR 4.00
cunendy in effect. Furrhermore, this installation has been tested in accordance with such requirements, h now in proper operatng condition and
complete instrucions .s ro its use and maintenance have been furnished to the pcrson for whom the installation (or alteration) was made.Tl ./J.1 C^Tel.:,Co. Name E
Ovcrire Drafr:
'o r-€yg e oSq
@1r\\-3'\w
Address F Fo/*-.-r/ tq
City:EI f ,%u'
-/zip:
)/
Date:-
lnstaller
Pnnr Narne Sr'gnatlre (no Sump)
Once signed by the fire department, tlis is a PERMIT for the storage and use of oil buming equipment.
Inspected by /-/.'/4/S___._O
WHTTE COpy: property owne/s copy; CANABY COPY: YF.D. Copy. neturn when iob ir completed; PINK CoPY.This copy ftrst be Posted at installation.
Alteration of Fud Oil Burning Equipment and the Storage of Fuet Oil-,/?