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Applicarion for Permit, Permit, and Certificate of completion for lhe InsBllalion or
Alteradon of FueI Oil Burning Equipment and the Slorage of Fuet Oilt/tiln{vfL,a-.- zr uo t
Owner/Occupant Namc:lod (,orT
lnstallaoon Serviced Floor or Unit t:
-EilHeating UDit
Bumer dNc,,
Trade Name: 4t d"*t Mfs:B.LL
EI Domestic warcr Heater E Power venr E Orher
E Existing locarion:4:e<.'*^rT
T1pC:Modcl # or Size:NF 3 Locarion:T
EI Fuei Oil EI Kcroscne EI Wasrc oil
Storage Tank E Ne", E(e*istiog Location:
Type:V-tT-Capaciry:?t'(
Special requiremens (or additional sdcry devices)
4*v","-rl
gals. No. of Tanks:
At A.wuq A^n TelL
E OSv val"c El-Oil tinc prorecled E Shcct Rock EI Sprinllcr AFUE: dycs E no
Combusrion Tesr: Nozzle Size .fo Lo 5 Gross Stack Tcrnp.:Itf
New Sack Tcmp.: CO lTcst luo ltl,f Breech Drafc -/
Overfire Drafr .L Efficiancy rating 7o:s(7Smoke:
Address 2Lr
lnstaller:l,.l , c
H**,,c\zip:U an {ftn/City:
Y1 o)Y0 L
Print Name (no SomP)
depa:tment this is a PERMIT for the s
Date:7
lnspected by:
31 ,lp^r,*
WHITE coPY: Property ownels copy; CANARY coPY: YFD'copy - Retun wier lob i3 comPlet€d; Plt{r coPY -This coPy must be P$ted at installation'
(Gry or Town)
Permit #'s: FD loovor Elcc. _ F:DIDrh O/ri /
afiz Comttonu) eo[t fL of fo{us o{tus et*
DEanrunt of e,rhfu Sofetg
527 CMR 4.00
Form I
(Datc)
Fce Paid: f ar, oo
Tct#. to?, '7 lf- 7YL7
4r-
)
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l, the undenigned cenif| that the installation of fuel buminS €quipmcnt has been made in accordancc with M.G L c' 148 and 52? CMR 4 00
;ilI, ";?;.; F;#ermore, this installation has becn t33ied'tn accordance with such requirements, is now in proTer operating condition and
.;;;il ;r;;;t..r "s
r., its use and maintenance have been fumished to the person fot whom the installation (or alteration) was made'
go.,,jaIrs 4tH L,),u Cnlnn Tel.# faL lJo V)tL
Once sig-rred bY the and use of oil buming equiPment'