HomeMy WebLinkAboutinstall burner 2013A.'
FP-56A
(Rcv. 04/10)
527 CMR 4.00 - Form 14
Certiflcate of Compliance
M.G.L. Chapter t4E, Sectlon 3EJ
City or Town:O/ruo rT/,
Street Name & Number:c/e r
Name of Property Owner:5r-t o/4 r/
This visual inspection and certification of compllance was completed on:
This certifies thst 8 visual inspection -ollhe luel supply line(s) for the aboveground heating oil storagetank wqs completed in accordance with M,G.L. cnapier 14E,'secdon 3sJ(d) fir ttre restaentiat propertyidentified above, and the following equipment was otservea and compliant:,''
6Eacn fusl supply and retum lina (if present) is enclosed with a continuous non-metallic sl6ev€
fl Each fuel supply lino is equipped with an oil safety valve
DatB:-Z
By: (Signaturs of Oil Burner Technician)
(Print Name o, Oil Bumer Technician)/,.7 Ua
Certificato of Competency #:DA zz57
Upon completion ofForm lA, the property owner shall receive a copy of the form and
a copy s.hall also be submifled to the head of the local fre departrnent or a desipee,
This form can bc pbotocopicd or rcproduccd in triplicatc.
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Permit #'s: FD
lfu Coffit otweattfi of lr{ossacfutsets
Depattnunt ,f gu6fu Sof"ty
527 CMR 4.00
Form I
Application for Permit, Permit, rnd Cenificate of completion for the lnsEllarion or
Alteretion of Fuel Oil Burning Eq pment and $e raee of Fuel Oil.?
&dc*t1a
ftut0u {./
(Gry or Town)@ate)
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Tct*.Jzl.-5'z/'52
Elcc.FDID#:
Owner/Occupant Name:
ln5trlhdsn Addrcss:
k la /'t-/28
€/
fJ Hcadng Unit
Bumcr: E] Ncw
Trade Name:
E gxisting location:
Mfg:
Modcl # or Size:Tlpe:Location:
E Fuei Oil E Kcrosenc f] Wasrc oil
Locadon:
2 25-,*
Spccial requiremcns (or additional sdery &vices)
Combustion Tcsr: Nozzle Size Gross Suck Tcrnp.:
New Stack Tcrnp.: COlTcst
-
Brcech Drafc
Smokc:Ovcrfire Drafr Efficiency radng 9o:
l, rhe undersigned certify that the installation of fuel huming equipment has been made in accordance with M.C L c. 148 and 527 CMR 4.00
.unently in ekect. Furthermore, this installation has been tested in accordance with such rcquirements, is now in proPer olcrating condirim and
.omplete i.r"t*ctions as to its gse and maintenance have been fumished to the pervrn for *hom the installation (or alteration) was made.
t-E o//City:
-8oo -7 zz- 6Yaa
lp:/L
re! 9 Te[.:rCo. Name
I /ror2a,
'-"a4/4
Address o
/&cuqylnstaller:Signalue (no Stump)Pnnt Name
Once signed by rhe. fire department, this is a PERMIT for the storage and use of oil buming equipment.
Date:
WHITE COpy: Property owne/s copyi CANAEY COpY: Y.F.D. Copy ' Relurn when iob b comPleted; PINK COPY 'This copy must be Posted al installation'
g
Serviccd Floor or Unit fr
-E Domesdc \tr/arcr Hcaer E Powcr Venr El Orhcr
Storage Tan$. d"* EI Existng
r,4,., Aa u ile uto l) capacity:gals. No. of Tants:
./,E OSv vaive El--oit tine prorecrcd E Shcet Rock E] Sprinklcr AFLIE: E ycs E no
//47"U.
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lnspected by: