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Form 1i C�L pOMW oo��la�✓�ac � r� 527 CMR1.00 Section 1.12.8.2.1 FP-056 Form 1 (Rev. 1.26.2015) Application for Permit,Permit,and Certificate of Completion for the Installation or Alteration of Fuel Oil Burning Equipment and the Storage of Fuel Oil (City or Town) (Date) Permit#'s: FD Elec. FDID#: 022 et Fee Paid:$ �G Owner/Occupant Name: `; Ln �� Q�PS installation Address I 1 t �J ` ` Serviced Floor or Unit#: seating Unit Domestic Water Heater ?Power Vent Other Burner: News Existing 0'1 Location: Mfg: Model#or Size:<� ^�()�� Nozzle size: Type: (�1r u� , Fuel Oil =1 Kerosene +-`Waste Oil DI Removal r: n Storage Tank: =f New €xisting Location: —"�lA Type: a'6Pi I Capacity:(-9_7!,�: gallons No.of Tanks: Special requirements(or additional safety devices) is OSV valve it Line Protected � j 1 F TeIXQ —say �� Co. Name: W� '1L� � �( Address- `Ie0bn `- City: �� mpg zip: c T Completion Date: �� Combustion Test: Gross Stack Temp.: Net Stack Temp.: rr a CO2 Test: t b Breech Draft: Smoke.- Overfire Draft: 6 Efficiency Rating%: I,the undersigned certify that the installation of fuel burning equipment has been made In accordance with M.G.L.Chapter 148 and 527 CMR 1.00 currently in effect.Furthermore,this installation has been tested in accordance with such requirements,is now in proper operating condition and complete mstru tions as to its use and maintenance have been furnished to the person or whom the installation(o io !(no made. Installer: © �'� �f SignatureSta p) Print Name Address: Once signed by the fire department,this is a PERMIT for the storage of fuel oil and use of the oil burning equipment. q Approved by: OLP� �IfA Date: �C) / Keep original as application.Issue duplicate as permit.This form may be photocopied.