Form 1 (revised 8/11/00)
The Commonwealth of Massachusetts
Department of Fire Services
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
______________________________________
(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
2
Test: _____________________ Breech Draft: _______________________
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.
NANTUCKET
19197
Form 1 checklist (revised 8/11/00)
ALL INSTALLATIONS
4.03 (1)d All applications must be on Form 1
4.03 (1)e Over 10,000 gallons on site requires License &
Permit from local community
4.03 (1)g Certificate of Competency required, no other
license acceptable, plumbing, electrical, etc.
4.04 (3)a Verify emergency shut-off is outside burner room
4.04 (4)b Verify separate circuit for oil burner
4.04 (4)e Verify presence of overhead thermal switch
4.04 (4)c Verify presence of service switch within 3' of burner
4.04 (3)b Verify presence of high limit controller
4 04 (3)c(1) Primary control has safety timing of 45 secs.
(max.)
4.04 (4)d Stack type primary may be easily removed
4.04 (3)d Steam boiler equipped with low-water cut-off
4.04 (4)f Clear access to clean out and services panels
4.04 (5)b No oil leaks present at burner
4.04 (5)d Installation instructions present on site
4.04 (5)f Overhead combustible clearances within 5 feet over
unit Gypsum board or sprinkler required unless unit
is AFUE (Furnace or Boiler) rated or EF (water
heater)
4.04 (5)g Combustion test results on Form 1
4.04 (9)b(12) Three metal screws at each joint in chimney
4.04 (9)b(7) Thimble present at chimney connection
4.04 (9)d IF POWER VENTER IS USED: Check air pressure
switch, post purge control and secondary control.
Installation instructions present.
4.04 (9)f Draft regulator is present unless exempted
4.04 (5)m Adequate air is present for combustion
4.04 (5)o Adequate clearances per manufacturers listing
4.04 (2)i Thermal valves at burner and tanks
4.04 (1)b Listed flexible hose may be used.
4.04 (1)c No Teflon tape on oil line or on oil line fittings
4.04 (1)c No compression fittings are permitted
4.04 (1)c Solder joints made with 500 degree F solder or
greater
4.04 (1)e All oil lines must be protected from injury. All new
lines must be continuously sleeved with non
metallic tubing. Oil safety valves may be used on
existing lines not exposed to freezing. Overhead
lines require no sleeve and are permitted
4.04 (1)f Oil lines exposed to freezing temperatures must
come off the top of tanks
Lines for kerosene, and range oil (#1) are exempt -
4.04 (1)i No oil leaks present at tank
4.04 (1)j Listed oil filter is present
4.03 (5)b Tank is UL80 or (DIB+) PV-VI 321 (under 660 gal)
or UL 142 (over 600 gal)
4.03 (5)e Shutoff valve located at bottom of tank
4.03 (5)f Size of vent as per Table 4.03A
4.03 (5)g Oil tank gauge must be present to determine oil
level
4.03 (11)c Inside tanks have audible fill device (vent alarm)
4.03 (5)j Outlet cross connection at bottom of tanks must be
1/2" pipe or tubing.
4.03 (5)l Non-combustible tank supports, tank secure.
Note To Installer: Inspections will be conducted using this
checklist as a guideline. Current regulations will apply.
UNENCLOSED TANKS
4.03 (6)b Single tanks shall not be larger than 660 gallons
4.03 (6)b Maximum aggregate capacity of unenclosed
multiple tanks is 1320 gallons
4 03 (6)d Unenclosed tanks shall be at least five feet from an
internal or external flame
4.03 (6)d Unenclosed tanks shall not obstruct service meters,
service panels and shutoff valves
4.03 (6)e Bottom outlet tanks pitched to the opening 1/4"per
ft.
4.03 (6)f Tanks exposed to vehicles will be protected by
barriers
ENCLOSED TANKS
4.03 (7)a Over 660 gallon tanks enclosed by two hour fire
resistive assembly
4.03 (7)b Tank enclosures provided with 6" high tight sills or
ramps
4.03 (7)d Tank is 4" above floor supported by 12" thick
masonry saddles spaced not more than eight feet
on centers and 15" from top and walls of enclosure
4.03 (7)e All oil must be transferred by pump, and
connections must be at the top of the tank
ALL TANKS
4.03 (9)d Two tanks may be cross-connected as shown in
Fig. 4.03 1.
4.03 (10)b Return lines must enter the top of tanks
4.03 (9)c Vent pipes must be two feet from building openings
4.03 (9)c Vent pipes must terminate 3 ft. above grade min.
4.03 (9)c Vent pipes must have weatherproof caps
4.03 (10)a Fill pipes must be two feet from building openings
4.03 (10)a Fill pipes must have tamper proof identifying caps
4.04 (9)d IF POWER VENTER IS USED:
All outside connections sealed Vent terminal must be three
feet above all air inlets within 10ft. Burner air intake is
exempted Vent terminal must be four feet from doors and
windows. Vent must be one foot above finished grade. Three
foot clearance from inside corners. Not above or within three
feet of an oil tank. Seven feet above a public walkway.
IF UNDER PORCH OR DECK: Heating use only, no hot
water. Four feet below deck AND not enclosed under deck
OUTSIDE TANKS
4.03 (8)a All UST's and tanks over 660 gallons must be
installed as per CMR 9.00
4.03 (8)c Tank protected from physical damage
4.03 (8)c Tanks exterior coated with organic alkyd resin or
asphalt paint
4.03 (8)c Damaged protective coatings must be recovered
4.03 (8)c Tank does not block means of egress
4.03 (8)d Tank mounted on continuous 4" thick slab that
extends 8" beyond tank perimeter
4.03 (8)d Tank is supported by rigid non-combustible
supports
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome