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527 CMR 4.00 Form '1
Application for Permit, Permit, and Certificate of Completion for the
lnstallation or Alteration of Fuel Oil Buming Equipment and the Storage of Fuel Oil
FP-056
(Rev.04i l0)y'rar ia-
(City or Town)
Permit #'s FD l0lq6 Erec
-
Owner/Occupant Name Jzorz'fu/ly'Arr,J.-,
lnsta ation Addresr, //2 fta22 5a
( Heatlng Unit E Domestic Water Heater
Burner: E New fr Existing E Location
ca\&l @Tet.#:.1d-362 .zeztl47z o?zo@
-7
Serviced Floor or Unit #
E Power Vent
Mfg:
Type Nozzle size
Type Capacity: J76- gattons No. of Tanks
Special requirements (or additional safety devices)
t
E osv valve JXo Line Protected E Sheet Rock E Sprinkler AFUEX yes L-j no
(tumace >nd boilers)
Co. Name Ut t+
Address City:
EF: E yes fl no
(waler heater)
Zip 0'?6q({
Completion Date
Combustion Test
Z
Gross Stack Temp
CO'?Test:
Nel
o e Draft:Effrciency Rating %
I, lhe lndersigned certify lhat the installation of fuel burning equipment has been made in accordance wjth M.G.L. Chapter 148 and 527 CMR 4.00
currently in erlect. Furthermore, lhis installation has been lested in accordance with such requiremon
complete instructrons as to its use and maintenance have been furnished to lhe person or whom the
is now in proper operating condition and
+€ss
Cert of (*atute (no
n(ora was made
Address ,4 Bn, z?s-City:
Once signed by the fire department a PERMIT for the storage ofluel oil aod use of the oit buming equipment.
DateApproved by:
Keep original as app lion. lssue duplicate as permit. This form may be photocopied
lz/
{*Wr-r-*r**r*lr/oy'tk'.'*tr.,"n
@7*ra**;/oZr"Q7r*,rb*
(D6te) ..-^
Fee paid $ -#-.4
Other
'7o<erne^tr
Model # or Size:
__Jq Fuel Oil E Kerosene E Waste oil
Storage Tank: (ruu* E Existing Location: ?rfiAr4&-rf
r"r* @:!'7ZJ-!E
Smoke: _
lnstaller:
FP.56A
(Rev.04/10)
Cily or Town:\
€2, 33*,-orro,rob/
(*./zz.{;e)-
527 C[/R 4.00 - Form 1A
Certifi cate of Compliance
M.G.L. Chapter 148, Section 3tiJ
1-
/6t (c*L;z- </.Street Name & Number:
Name of Prope,ty Owner Jaorr D,lt*.nl,
This certifies that a visual inspection of the fuel suppll line(s) for the aboveground heating oil storage
tank n'as completed in accordance rvith M.G.L. Chapter I.18, Section 38J(d) for tbe residential propertl
identified above, and the follorving equipment n'as observed and compliant:
( Eacn fuel supply and retum line-(if present) is enclosed with a continuous non-metallic sleeve
! Each fuei supply line is equipped with an oil safety valve
Date 7/ z/,"
By: (Signature of Oil Burner Technician)
(Print Name of Oil Burner Technician)
Dz^g.tz 6
Upon compietion ofForm 1.4,, the properq oli,ner shall receive a copl ofthe form and
a copy shali also be submitted to the head of the local fire departnent or a designee.
This form can be photocopied oi- reproduced in tripiicare
Z4r-,rf,.r.-rZ/eZz*,
This visual inspection atrd certificatioD of compliance rvas cnmpleted on.
Ce(ificate of Competency #:
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W,t,,-l "lJr* &^,,*b - W "{il* [t l, J*Til-,ol*l
P.0. 8", 1025, ltol, Ro"l, At"*, mA UWs
rl,irlit,li
APPLICATION FOR PERMIT
Yarmouth
06/28 / 2Ot2
Permit Number: 101099
ln accordance with the provisions of M.G.L. Chapter 148, as provided in Section 10 A application is hereby made
by:
For permission to: Above Ground Tank Removal 527CMR 9.02
Name of Competent Operator Oil Burner Service 508.477-1115
Date lssued-Rejected 06 / 28 / 20L2 By
Date of Expiration: O7 /30/20L2 Fee
THEUOl
CENT12
Cert. No
$ Paid
(Signature of applicant)
Due
ri,ii!il,li Crr-,***//6 r/ fk ""&r4r1,W^ t $ Jr* [u**," - W'1 il* [t h ff* T[1"^l*l
P.0. E* 1025, [t"], nool, &o*, mA U115
PERM!T
Date:06 /28 /2Oa2
Permit Number (if applicable) 101099
ln accordance with the provisions of M.G.L. Chapter 148, as provided in Section 10 A this permit is granted
to: Oil Burner Service 50A477-1115
For permission to: Above Ground Tank Removal 527CMR 9.02
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 162 Center St lYarmouthPort, MA 02675
DIG SAFE NUMBER
Start Date:
Fee Paid $te on 0713012012
Signature of Official Granting Permit
This permit will exp
Title )e v)enqvd-
This permit must be conspicuously posted upon the premises
City or Town:
Date:
Address: '162 Center St /YarmouthPort, MA 02675
City or Town: Yarmouth
Make apPlication to local Fire Department.
Fire Department retains origlnal application and issues duplicate as Permit
ior slorage tank removal and transportation to approved tank disposal yard in accordance with the provisions
of M.G.L. Chapter 148, Section 38A, 527 CMR 9.00, application is hereby made by:
\\A ,.i,*-\0lCqq
Fee
City or Town
Date ol issue Glkt\,\8
FDID#
Date of expiration o
Pe
I
Dig safe approval number:
Signalure / Title of Of,icer L},granting permit
Afler removal(s) ("Consumplive Use" fuel oil tanks exempted) send Form FP.290R signed by Local Fire Dept, 10 UST Regulatory
Compliance Unlt, Department ol Fire Services, P.O. Box 1025, State Fload, Stow, MA 01r/5-
'lnl6rnational Fire Code Institule
stgnatue lil aPptynglot ,{mn)x
L+
AV
nol,.Q.-t-DlTank Owner Name (plsase print)
Address
uu, TAIL (enw t t S*rruic-
4661ss* r, i.\l^,tA{E 4{r^.-ls
Other
Company
orSignature (il ap
tr lFCl' Certlfisd
Address
-
Prlnt
/
signature (if applying for
tC,
Co. or lndividual
E lFCl' Ceriilied 0 LSP
Ce^r/<.,
027<Substance Lasl Stored
{
*.,1*2, G^Tank Capacity (gallons)
Tank Localion
Tank Dlrnensions (diameter x length)
Remarks:
I
Firm transporting waslB State Lic. #
E.P.A. #
lo)Tank yard {
Tank yard address
/,L Z
.j"'2 7?--
Type ol lnerl gas
Hazardous waste manllesl#
Approved tank disp.psal yard
D oll Free T I. Number - 800-322-4844
TankOwner
Tanklnfotmation
Contamination AssessmentBemoval Gontractor
Wrr*rr*r.""*mr/ol4*nt*raa
@"V* a"-r.,1 ./&,,;* &*"r;*" - @ffi*,/d, &t"n&,;*at//.r.ot""l
APPLICATION and P:ERMIT
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