527 Cmr 4.00 Form 1 - Application For Permit, Permit And Certificate Of Completion For The Installation Or Alteration Of Fuel Oil Burning Equipment And The Storage Of Fuel Oil - The Commonwealth Of Massachusetts
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1
2The Commonwealth of Massachusetts
527 CMR 4.00 Form 1
Application for Permit, Permit, and Certificate of Completion for the
Installation or Alteration of Fuel Oil Burning Equipment and the Storage of Fuel Oil
FP-056
527 CMR 4 Form 1
______________________________________
(Rev. 01/09)
(City or Town)
(Date)
______
______
_______
______
Permit #'s:
FD
Elec.
FDID#:
Fee Paid: $
___________________________
__________________________
Owner/Occupant Name:
Tel.#:
__________________________________
__________
Installation Address:
Serviced Floor or Unit #:
■
■
■
_____________________
Heating Unit
Domestic Water Heater
Power Vent
Other
■
■
■
____________________________________________
Burner:
New
Existing
Location:
____________
_________________________________________________
Trade Name:
Mfg:
_________________
________________
______________
Type:
Model # or Size:
Nozzle size:
■
■
■
Fuel Oil
Kerosene
Waste Oil
■
■
________________________________________
Storage Tank:
New
Existing
Location:
_________________
_____
_____________________
Type:
Capacity:
gallons
No. of Tanks:
____________________________________________
Special requirements (or additional safety devices)
____________________________________________________________________________
■
■
■
■
■
■
■
■
OSV valve
Oil Line Protected
Sheet Rock
Sprinkler
AFUE:
yes
no
EF:
yes
no
(furnace and boilers)
(water heater)
_______________________________________________
_______________
Co. Name:
Tel #
________________________
________________________
__________
Address:
City:
Zip:
________________________
Completion Date:
_______________
Combustion Test:
Gross Stack Temp.:
Net Stack Temp.:_________________________
_____________________
_______________________
CO
Test:
Breech Draft:
2
_____
__________________
__________________
Smoke:
Overfire Draft:
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 4.00
currently in effect. 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 whom the installation (or alteration) was made.
Installer: ____________________________________________________________________________________________________
Print Name
Cert of C#
Signature (no Stamp)
Address:_________________________________________________________________________City:__________________________________________________
Once signed by the fire department, this is a PERMIT for the storage of fuel oil and use of the oil burning equipment.
Approved by: __________________________________________________________________________
Date: _______________________________________
Keep original as application. Issue duplicate as permit. This form may be photocopied.
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