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City or Town:
Date:
Yarmouth
04/09/20L3
permit Number: 101271
ln accordance with lhe provisions of M.G.L. Chapter 148, as provided in Section 10 A application is hereby made
by:
Address: 188 Berry Av /South Yarmouth, MA 02664
For permission to: lnstall Oil Burning Equipment/tanks
Name of Competent Operator winslow pi 394-7778
Date lssued-Rejecled 0 4 / 09 / 2OL3 By
Date of Expiration: 05/09/20L3 Fee: ss0'00 $Paid
Cert. No.
(Signature of applicant)
Due
THEUO1
BERR12
APPLICATION FOR PERM!T
I t.. \o7*J
'24* Zr*.; / &* e;ff^"r;*,
527 CMR 4.00 Form 1
Application for Permit, Penait, and Certificate of Completion for the
I-ustallation or Alteration ofFuel Oil Burning Equiprrent and the Storage ofFuel Oil
(City or Town)
EIec FDID#oai6l Fee Paid: $
FP-056
(Rev.04/10)
Permit #'s: FD
Owner/Occupant Name
lnstallation Address
E Heating Unit
rel.#: 568 t+ 5"L3
8
omestic Water Heater E Power Vent
Serviced Floor or Unit #:
Other
BurneT: 7(e* n Existing E Location
Mfg:
Typ"
(Fuer oir
Storage Tank: E New
tr Kerosene
%-
Capacity 2K r.uon No. of ranks
lvlodel # or Size
isting Location
L-d*Nozzle size
E waste oit
T
Type
L-..1 u5v valve Jl
dOil Line Protected L-l Sheet Rock E Sprinkler AFUE: E yes E no EF
(iurnace and boilers)
Tel #
Zip.
pv"s- no
(water heater)
Co. Name
c
Address
Completion Date:
Combustion Test:Gross Stack Temp
CO'? Test
Smoke: 0 Oveffrre Draft:
l, the undersigned certify that the installation
currently in eflecl. Furlhermore lhrs installati
City
of ruel burning equipment has been made
Net Stack Temp
Breech Drbft:
Efficiency Rating %:
in accordance with M.G.L.
o3
L
Chapter 148 and 527 Clt R 4 00
p per operating condilion and
liecomplete i ons as to its use and intenance have furnished to the person or whom the jn
lnsla ei-
Cefl ol Cl
Address City
Once signed by the ilre depad
/
on has been lesled in accordance with such requirements is now jn
ng equipmenl
Date
R
is a PERI\,4IT for lhe storage ofluel oil and use of the oit
Approved by
Keep origina as lication. lssue duplicate as pe.mit. This form may be photocopied
Special requirements (or additional saiety devices)
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