Application Form For Permit, Permit, And Certificate Of Completion For The Installation Or Alteration Of Fuel Oil Burning Equipment And The Storage Of Fuel Oil - Department Of Fire Services

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The Commonwealth of Massachusetts
Department of Fire Services
527 CMR 1.00
Section 1.12.8.2.1
Form 1
FP-056
(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#:
Fee Paid: $
_____________________________
___________________________
Owner/Occupant Name:
Tel.#:
___________________________________
__________
Installation Address:
Serviced Floor or Unit #:
______________________
Heating Unit
Domestic Water Heater
Power Vent
Other
_____________________________________________
Burner:
New
Existing
Location:
____________________________________________
Mfg: _______________________________________
__________________
_________________
_______________
Type:
Model # or Size:
Nozzle size:
Fuel Oil
Kerosene
Waste Oil
Removal
_________________________________________
Storage Tank:
New
Existing
Location:
__________________
______
______________________
Type:
Capacity:
gallons
No. of Tanks:
_____________________________________________
Special requirements (or additional safety devices)
_______________________________________________________________________________
OSV valve
Oil Line Protected
_________________________________________________
________________
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 1.00
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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