Form 22 (003) SALEM FIRE DEPARTMENT
Fire Prevention Bureau
48 LAFAYETTE STREET, SALEM, MASS. 01970
Date . . . . . .J. l . . . . . . . . . .
Certificate of Completion - Installation or Alteration of Oil Burning Equipment
The undersigned hereby cgrtifies th t the i sta11 tion (or alteration) of fuel oil burning equipment and/or storage tank and applying to the installation for
(Name of Owner) ..jY�.IG.. C� �.....�C�.n.ncl.rL Floor heated
1 .............................I.........
at Address .....��. �1�%-E.h.v2ne \U�' by system....(lst,2t2nd
( ) (lst,2nd,all)
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
f \ � (r n
Name.. ( .���.1CJ.................................................. Mfg. by..j. \l�... � 4Ur7P....................
Type...'f.lC4 YY��.... �� ....................I.......... Mass.Approval No. ....L 0.3 ....................................
To use not heavier than...�fb.L.............fuel oil....................... Kind of heat..........f7.fm.................'....................
(D.H.W.;F.H.W.;STEAM;F.H.A.)
p STORAGE TANK
Type of Tank.... -1........................................................... [ ]New Tank
No. of Tanks........I......................Total Capacity.4 ............. ]Existing Tank
Location....10Q.S C-vy\Q n f......................................................... [ ]No additional storage,using same tank as another unit.
Note: New underground tank installations,require a plan and Form 81G to be filed.
Type(automatic or manual)control..... !M .,T`l L...........................................................................
Location of automatic shut-off valve......... nt !�J�? -���2-
Location and type of manual shut-off valve...�A.C--..�P.K-0 07.... LECTRICAL CONTR/A�CTOR:n
Special requirements.......................................... Company. �IC kee-.�.n ....V L,. ..Co.M�.'.Y.-�............By .....
. ................. .............................
writte sign tur
Cert.ofGpmp.Rec'd.......... .................. ......
�. .. [... ./... . . ......I.. ... ............... ,
Permit issued.................................. Address.. .O....Cl.......... �!{95�}IPi ............
Issued By**..... ....... Installer's Certificate of Competency No........l. .�V .............,...........
DO NOT WRITE BELOW THIS LINE
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