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Oil Burner Install
SALEM FIRE DEPARTMENT Fire Prevention Bureau 48 LAFAYETTE STREET, SALEM, MASS. 01970 �r Date . . . . .w/.!�.� .`,. �. Certificate of Completion - Installation or Alteration of Oil Burning Equipment The undersigned he�rtifigs t the installation(or alterr4ion) of fuel oil burning equipment and/or storage tank and applying to the installation for (Name of Owner) .....J!......../ D,✓/i�[,C...-... ✓..�.��3... .� a....��i......-- ---.. Floor heated ,�J at(Address) `D�Y?/✓14 /� C . Tel. by system..................41.1............... ............. ...............`A.�....5. ... ��.,.�.f...d�. �... (lst,2nd,a11) has been made in accordance with provisions of the Salem Fire Prevention Code,of Chapter 148,G.L.,and regulations made under authority thereof now currently in effect and pertaining thereto.(Ref.527CMR4.00) Furthermore,this installation has been tested in accordance with such requirements,is now in proper operating condition and complete instructions as to its use and maintenance have been furnished to the person(or persons)for whom the installation(or alterations)was made. BURNER Name........................ Mfg. by.......................... ............................. ...... ............................... ? Type. Mass.Approval No. .........�a %J ...'.. ti To use not heavier than.........�...........fuel oil....................... Kind of heat................6 f�b✓ ................................ (D.H.W.;F.H.W.;STEAM;F.H.A.) { STORAGE TANK Type of Tank............d �1..... ............ ....................................... ( ]New Tank No. of Tanks..................................Total Capacity.........7. ................ (1, EaistingTank Location...........l J 1.j.1.A-e..................................................... ( ]No additional storage,using same tank as another unit. Note: New underground tank installations,require a plan and Form 81 G to be filed. Type(automatic or manual)control.............................................................................................................. Location of automatic shutoff valve...................................................................................'..,.............` Location and type of manual shutoff valve................................. ....ELECTRICAL SONTRA gOR: '�o4lo l d.... "' Special requirements.......................................... Company.......�. a....., ✓. `!`}A. ............ By................ (wri n ignature) Cert.otGpmp.Rec'd....... ....... .. .... ............... Permit issued.),T.� ................. Address.......... © .�..... . .5/......!?.....:............. Issued By..G f .......................... Installer's Certificate of Competency No........... .A._.7................. DO NOT WRITE BELOW THIS LINE SALEM FIRE DEPARTMENT Fee Du $10.00 Fire Prevention Bureau Received by . . .told. . . . . . 48 LAFAYETTE STREET, SALEM, MASS. 01970 a Cash- Excerpt from 527CMR4.02(2)(g).NO PERSON shall install or alter any fuel oil burner without FIRST making application to the head of the fire department and obtaining a permit therefor. Application for Permit to Install/Alter Oil Burning Equipment Application is hereby made in accordance with the provisions of Chapter 148.G.L.and Regulations made under authority thereof by the undersigned for per- mit to install/alter,for the person or persons and at the location named herein,certain equipment for the keeping,storage or use of fuel oil or flammable liquid pro. ducts used for fuel as described below. .J I `�C�Jic/�G ..- �; /�' /�✓7/� ....� �.^Ji..L..... Date......�:�. /��....t�.Name of Owner..................... ... ....../... J`............ /.. / . �f........ r/ s Floor heated Address...........................`..... by system........1,/�!�.`�.C.!.!9.�.....J. .............................. �I............. (1st,2nd,all) .......................BURNER Name.............................. //'✓ Mfg.by..............""fJ.. .. .✓ ............................. Type...........................W. .✓.................................. Mass.Approval No.............. Type of heat........... I.................................... / (D.H.W.;F.H.W.;STEAM;F.H.A.) ( )New Tank Location of Tank..... ®V / J STORAGo T E TanksTANK / [Existing[L/Existing Tank Type of Tank......... (� L../................Capacity....v gals. Type of fuel...... ..................... ( J No additional storage,using same tank as another unit. ELECTRICAL CONTRACTOR..®�?.✓?fl:, ......C�J„ /.' This application is made with full knowledge of the current requirements of the regulations governing such installation,,which will be made in compliance therewith. Q 7 4r Company............................. .!. .. ..... !7 1 ........ Appl. Rec'd.........t-*4 q/........... By ..:............... —7 (wfritten luulr-e) Premit Issued...... .l.��l// �........ Address ......../..... �'�.`:.......S.!.........1. `j!9../Y�!1...... Permit No................................... Installer's Certificate of Competency No.........017.3.6. ................. A self-addressed(Installer's name and address)stamped envelope must accompany this application. Note: New Underground tank installations,require a plan and Form 81 G to be filed. Form No.22(Rev. 1 1/82) DO NOT WRITE BELOW THIS LINE