The Commonwealth of Massachusetts
Department of Public Safety
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
TOWN OF SHREWSBURY
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: __________________
Special Requirements (or additional safety devices): ____________________________________________
______________________________________________________________________________________
OSV Valve Oil Line Protected Sheet Rock Sprinkler AFUE: Yes No EF: Yes No
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. c. 148 and 572
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 for 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 and use of oil burning equipment.
Approved by: _____________________________________ Date: ________________________________
Keep Original as application. Issue duplicate as permit. This form may be photocopied.
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