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APPLICATION FOR PERMIT
City or Town:
Date:
Yarmouth
o8 /28 /2Ot3
Permit Number: 101336
ln accordance with the provisions of M.G.L. Chapter 148, as provided in Section 10 A application is hereby made
by:
Address: 24 Captain Wright Rd /South Yarmouth, MA 02664
For permission to: lnstall Oil Burning EquipmenUtanks
Name of Competent Ope1s1s1; K&J Heating & Cooling p: 77 4-77 3-5732
Date lssued-Rejected Og / 28 / 2013 By
Cert. No.
re
Date of Expiration 09 / 30 / 20L3 Fee: Sso.00 $ paid
THEUOl
c4PT400038
Due
s\atrz, Comrunut ea[t fr. of l[tss airus et*
Deportnazt of Pu6fu sofety
527 CMR 4.00
Form I
Application for Permit, Permit and Certificate of completion for the Insullarion or
Atteration of Fuel Oil Burning Equipment and the Storage of Fuer Oil
(Ciry or Town)
Permit *'s: FD Bcc.FDID#:
Owner/Occr:pant Namc:Tci tt
O Hearing Unit
Bumer: El New
Trade Name:
E Fuei OiI E Kcmscnc E] Wasc oil
Storage Tank E Ne,, EI Existing Location:
TyPe Capaciry:
Speciai requiremens (or additional sdcry dcvices)
tr Existing l.ocadon:
Mfg:
Locadon:
gais. No. of Tanks:
New Suck Tcmp.:
Smokc:
E OSv vaivc E oit tinc protccred tr
Combustion Tcsr Nozde Size
Shcct Rock E SprinUcr AFIJE: Ei yes tr no
Gross Suck Tcrnp.:
Brcech Dnfc
zip:
CO rTcst
Co. Name
Address:i' i- l .,/J City
ln.t aller:
-
Inspected by: ty'- -') - /.F-r - Date
Pritu Nart! L..-- ' // SiS,1dx.r€ (no S@n )
Once signed by the f,ire department, this is a PERMIT for the storage and use of oil buming equipment.
WHITE COPY| Property owne/s copy; CANARY COPY: Y.F, D, Copy - Relurn when iob is completed; PINK CoPY . This copy must be poited at installation
lnstell isn Ad&css: Sen iced Floor or Unir f,
EI Domestic Warcr Hearcr E Powcr Venr E Orhcr
(Dalc)
Fec Paid:
Type: _ Modcl # or Size:atl /J.
-*
/4'tz
Ovcrfire Drafr .- Efficicnry radng 9o:
l, dre undersigned cenify that the installation of fuel buming equipment has heen made in accordance with M.G.L. c. 148 and 52? CMR 4.OO
currently in effect. Furthermore, this installation has bcen tested in accordance with such requirements, is nou, in proper opcrating condition and
complete instructions as to its us€ and maintenance have been fumished to the person for whom the insallation (or aheration) was made.
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