Form 22 (002) �.Co90RA,td
SALEM FIRE DEPARTMENT Fee Due$10;RO_,
? Fire Prevention Bureau Received by . . .
�J'�t�/11IML��SY 48 LAFAYETTE STREET, SALEM, MASS. 01970 Ck.# 4225 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 Date ........ .... ..............
Name of Owner... t... .. ........................�./1/.. 0 ...
//�, '' h t� /I� Floor heated
Address........................ .. .. ..•.........� ..U. .......... by system..............'.............
(1st,2nd,alp
BURNER
Name................................................................... Mfg.by..........................................................
Type.................................................................... Mass.Approval No.................................................
Typeof heat......................................................
(D.H.W.;F.H.W.;STEAM;F.H.A.)
STORAGE TANK
4NewTank Location of Tank.................... No. of Tanks.........
[a ] Existing Tank Type of Tank........Jam'.. .G�..,.........Capacity.. ./1✓......gals. Type of fuel.......;o�..................
[ ]No additional storage,using same tank as another unit. ELECTRICAL CONTRACTOR.........................................................
This application is made with full knowledge of the current requirements of the regulations governing such installation,,which will be made in compliance
therewith. Company... `.'
................ ........ .. ...,........................
Appl. Rec'd................................. By.......... .. --- re .
CT //��,,��(w tten signature) /7
Premit Issued............................... Address ...�.�✓57....!f!cv$.J .... .� .O.-A.�.-A
Permit No................................... Installer's Certificate of Competency No.....�.../.�..f ...............
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. 11/82) DO NOT WRITE BELOW THIS LINE