Installation of Burner COY�A
SALEM FIRE DEPARTMENT Fee Due$10.00
z Fire Prevention Bureau Received by . . . . . . . . . .
48 LAFAYETTE.STREET, SALEMF MASS. 01970 . Ck.#Cash
s 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 name1�d'he(reiin,certain a pm tt for th keeping,storage or use of fue o•I or flammaabl li ui itvd'•
ducts used for fuel described below. D� /EjIL., � � i; �j / ,V� yo
ti.Name of Own16r ... �............................ Date .. :. ............
... ....................... . . ....
Address........ ! �f3" .......... . jJ Floor heated
........... o,� j���f p by system.............. .
BURNER
Name.......!! V �p �.�!..... Mfg.by ......( �L ..�J......Gt�/.".........
Type............................ ....... Mass.Approval No..C....:.
Type of heat.......... .................
(D.H.W.;F.H.W.;STEAM;F.H.A.)
STORAGE T{ONK I
( )New Tank Location of Tank... ./—s Y)1)SOI)d4?9-lllhW0"' Tanks.�C7 �C
Existing Tank Type of Tank... .��.....................Capacity...(-7-Z . gals. ype offue.l...... ....................
( ]No additional storage,using same tank as another unit. ELECTRICAL CONTRACTOR.......... I............
This application is made with full knowledge of the current requirements of the regutat governing as ,;h in tal tion„ hich will be e in c pliance
therewith. LL � ..
Company......,;'.......` ...
Appl. Rec'd........ .: .:.... By ........l�J.... Z.Z.�03.�4
(wri�tte�isignaYLre) /q!�� �'�'
Premit Issued............................... Address .. ......./ "
Permit No................................... Installer's Certificate of Competency No....u.Q. y.7
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
i
SALEM FIRE DEPARTMENT - INSPECTION REPORT
. ADDRESS;
NAME OF OCCUPANCY: Q ��� _�� TYPE OF
cJ OCCUPANCY
P.T.N. C-4,el,, 7�l� ADDRESS
r--
BLDG. OWNER 6��;ZyLy,�r ,.y ADDRESS TEL
--------------------
________ANSWER ALL_OUESTIONS__EITHER "YES"1_"NO"l_OR_ 'NONE '__
1. Are the approaches to the building free and clear?
47
2. Does the area adjacent to the building, appear to be free
of rubbish accumulations , or other fire hazards?
3. Are facilities provided for the safe disposal of rubbish?
4 . Are all outside egress paths free from any obstructions
that may interfere with the safe exit of the occupants? N >
5. Do porches and fire escapes, appear to be in a safe
condition and 'free of obstructions? �
6. Do outside sprinkler and standpipe F.D. connections
appear to be in good and usable condition? _��
7 . Are entrances and hallways clear of any obstructions
that may interfere with the emergency exit of occupants?
8. Are all interior occupied spaces clean and consistant
with good housekeeping practices?
9 . Are all necessary Licenses and Permits posted & dated?
10. Are the occupants complying .with all regulations and
conditions, as prescribed on the Licenses and Permits? ��,,
11. Are all vertical shafts and stairwells properly safe- sue
guarded and provided with self closing devices?
12. Are all portable fire extinguishers readily accessable
and have they been inspected and properly tagged?
13. Does this occupancy have a fixed fire extinguishing
system?
Date of last inspection?
14 . Does this occupancy have a standpipe system?
Are all pressures satisfactory? Are standpipe hoses
provided? Is a gauge provided at top of system? _
15. Does this occupancy have a sprinkler system? --
. Are all pressure gauges showing satisfactory readings?
Are all O.S. &Y. valves open and padlocked?
Is a gauge provided at the top of the system?
16 . Is this a "WET" or "DRY" system?
Form #16 (Rev. 1/79)
17.. Does this occupancy have an interior fire alarm system? �—
18. Date of last test of the interior fire alarm system?
19. Does this occupancy have a direct Fire Alarm connection? _
Master Instant — --�
Type :Box #-1 y ADT# Alarm V AFA# 3M# Other
20. Is emergency lighting system or units provided?
21 . Are all emergency lighting units in good operating condition?
22. Does the occupancy have any unusual condition which would
constitute a special fire hazard? --
23. Are all flammables stored in proper containers and/or
stored in an approved storage area?
T
24 . Are all areas used for storage maintained in a safe manner?
25. Are basement areas free of any rubbish accumulation?
26 . Does the heating system, including the chimney, appear
to be in a safe operating condition?
27. Is a current fuel oil permit posted and storage proper?
28. Are there any electrical hazards?
29. Does the occupancy appear to have any structural defects?
30. Has a Form 25D (Inspection Recommendation Form) , been made
and issued for this inspection?
Write a brief description of any violations discovered during this
inspection. If the violation requires an early Fire Prevention Bureau
notification, file a Form• #58 (Complaint Form) If the violation
appears to require immediate action, notify the Deputy Chief on duty.
List each remark with item number for identification.
Name of person to whom Form #25D was issued:
Date: L
Inspected by:
/ Approved by : _
Approved by
ompany Officer
D.C. in charge of Insp. Date :
Form #16 (Rev. 1/79) P.T.N. checked by F.A. L
I