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APPLICATION FOR PERMIT
City or Town:
Date:
Yarmouth
02/L4/20r4
Permit Number: 101413
ln accordance with the provisions of M.G.L. Chapter 148, as provided in Section 10 A application is hereby made
by:
Address: 21 Cedar St /South Yarmouth, MA 02664
For permission to. lnstall Oil Burning Equipmenutanks
Name of Competent Operator:scudder & tavlor o: 774-994-0772
Date lssued-Rejected 02 / 14 / 20L4 By
Cert. No.
Fee: S50.00 $ paid
(Signature ol applicant)
DueDate of Expiration.. 03 / 14 / 2OL4
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PERMIT
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City or Town: Yarmouth
Date:02/L4/zOL4
Permit Number (if applacable) I C I '1 1 l
ln accordance with the provisions of M.G.L. Chapter'148, as provided in Section 10 A this permit is granted
to: scudder & taylor pi 774-9944772
For permission to: lnstall Oil Burning Equipmenutanks
Restrictions: Strict and complete compliance with all federal, state and local laws, rules, regulations and codes.
Notify YFD before and after work is complete.
At 21 Cedar St /South Yarmouth, MA 02564
DIG SAFE NUMBER
Start Date:
s50.00Fee Paid $This permit will expire on 0311412014
Signature of Officral Granting Permit Title
This permit must be cons icuousl posted u n the remrses
ii,iiirit,iiiilr
tfiz Comnonanattfi. of lr{ar atfiusetts
Deporanart ,f f"hti" Safety
527 CMR 4.00
Form I
Application for Permit Permif and Certilicate of completion for rhe Insullarion r
Alteration of Fuel Oil Burning Equipment and Storage of Fuet Oil
(Ciry or Town)@ale)
Permit #'s: FD 4\FI
A
{rl
1 fi-Owner/Occupant Namc:
[nstell4fel Addrcss:
EJ Heering Unir
Bumer: E Ncw
'rJ
l.ocadon:
Tcl #:
Locadon:
Trade Name:o,
tr a*ag
a'6rr Mfg:
Tlpe:Model # or Size:
Type:Capaciry:
Spccial requiremcns (or additional safety dcvices)
Ah
d{"o ou E Kcrcsanc E tv:src oit
Storage Tank E New d{or*g Location:R +
gals. No. of Tanls:
Ei osv vaivc OiI linc
Combusdon Tcsr Nozzle Sizc
Ncw Stack Tcmp lTcsr
un).1,''co Breech Drafr
E Sheer Rock E Sprinllcr AFUE: E ycs E no
Gross Stack Tcms.:
Te[. *
Ciry:zip:
*y
,7{
/0'l
Smoke:Overfire Draft -0/Efhcicncy rating 7o
I, the undersigned cenifu that the installation of fuel buming equipment has been made in accordance with M.C.L. c. 148 and 527 CMR 4.00
currently
complete
in effect. Funhermore, thts installation has been tested in accordance with such requiremenrs, is now in prop€r operating condition and
insttucrions as ro its use and maintenance have been furnished to the person for whom the installation (or alteration) was made.
a
Co. Name fLt
Address 'l'4^
gf
lnstaller:L7
lnspected by:
d
Pnnt Name
4
Sigranre (no SomP)
Once signed by the fire department, this is a PERMIT for the storage and use of oil buming equipment.
Date:lltl\\qt-
wHlTEcoPY:Propertyowne/scoPy;CANARYcoPY:Y.F.o.copy"Returnwheniobi3compbred;P|NKcoPY.Thiscopymustbepostedalinslallstion.
FDID#:_-Fcc Paid:
I
)1-7)7;
,4/Scrviced Floor or Unir +i
-E Domestic warcr Hcarcr E Powcr Vcnr EI Other
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