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APPLIGAT!ON FOR PERMIT
City or Town:
Date:
Yarmouth
permit Number: 100684
ln accordance with the provisions of M.G.L. Chapter 148, as provided in Section 10 A application is hereby made
by:
Address: 34 Captain Wright Rd /South Yarmouth, MA 02664
For permission to: lnstall Oil Burning Equipmenutanks
Mike Walker pi 737-2825 Cert. No
Date lssued-Rejecled lL / 02 / 20Lo
Date of Expiration: 02/ 02/ 20LL
By
Fee: S25.00 $ paid
(Signature oI applicant)
Due
TH EUOl
44PT400042
LL/02/2OLO
Name of Competent Operator:
\
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s\atrz Coruttorweattfr of Massacfus et*
Deporanatt of 9"6fu Sof"ty
527 CMR 4.00
Form i
Application for Permit, Permit, and Certificate of completion for the Insrellarion or
Alteration of Fuel Oil Burning Equipment and the Storage of Fuer Oil
(Ciry or Town)(Datc)
Fee Paid:FDID#:Permir.*'s: FD \S
f1,r.." lVV l-LOwner/Occupanr Name:
[n3t-ll4ie11 Ad&ess:
*,)LJ
I C rxl\UJnin.;'S.*,.S3"9,1;+*r* ry{
EJ Hcrring Unit E Domcstic Warcr Hcarcr E] Powcr Vcnr E Othcr
Bumen E Ncw(-)El-ggsdns
V'
Trade Name:
Location:
Mfg:
Ty pe:Modei # or Sizc:
EI Fuel oil E Kcrosene E Wasrc oit
Storage Tank E New E Existing Location:
Capaciry:
Locarion:
l-Yr e|l\l t
l(ot z1{ga.ls. No. of Tanls:4Type:t-,t,'utz(r Ltht (/
Speciai requiremens (or additional safcry &vices)
E OSv Valve E Oit tine protected E Sheet Rock EI Sprinlicr LFtIE: E yes E
Gross Suck Tcrnp.:
ao
Combusrion Tcsr: Noz:le Sizc
(/,twl/o*{t
L\
Ncw Sack Tcrnp.: CO lTcst Brcech Drafc
Smoke:or",firJPrrlft Efficicncv r:ilne qo:
l, the undersigned cenifi that dre installation of fuel buming equipment has be€n trude in accordence with M.C.L. c l{8 and 527 CMR 4.00
cunently in effect. Furthermore, this installation has been tested in accordance with such requirements, is now in proper operati[g condidon and
complete instrucrions as to irs use and ruintenance have been fumished to the person for whom the installauon (or altcration) was made.
rJ Tel *5oCo. Name
zip:Address:City /L
Installer:
Pnnr Namr:
Once signed by the fire department, this is a PERMIT for the storage and use of oil buming equipment.
rlre (no SFnP)
Inspected by: Date:-
WHITE COPY: Property owne/s copy; CANARY COPY: YF.D, Copy. F€tum vrhen iob b compl€ted; PINK coPY'Thie copy musl be posted al installation
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