Town of Westminster

Board of Health - (978) 874-7409

BOH Permit # __________ 11 South Street, Westminster, Massachusetts 01473

Outdoor Hydronic Heater (OHH)

Permit Application: Fee $110.00 payable to The Town of Westminster

Outdoor Hydronic Heater: Residential _________ Commercial _________

Name:____________________________________ Telephone:__________________

Address:________________________________________________________________

Please attach all required information. Your application will not be complete without all documentation and payment of the application fee.

Dimensions of the Outdoor Hydronic Heater: _______Proposed stack height__________

Name of Unit Manufacturer: _____________________ Model: __________________

Date of Manufacture: ________________ Date of purchase: ___________________

Distance of OHH to Property Line: (min 50 ft: residential; min 275 ft: commercial _____

Distance of OHH to Nearest Neighboring Occupied House (min 150 ft: res, min 300 ft com)____

ATTACH PLAN OF SITE: Informal if setbacks 2 times greater ______stamped______

ATTACH A COPY OF THE OHH EMMISSION TAG to verify Phase II compliance_____

I have received a copy of the Board of Health Regulations regarding Outdoor Hydronic Heaters. __________________________________ _____________

(Signature) (Date)

I have reviewed and understand the manufacturer's installation and operating instructions.

__________________________________ _____________

(Signature) (Date)

Town Department Signoffs are required prior to BOH approval for operation

Building:__________________________________ Date:_______________________

Wiring:___________________________________ Date:_______________________

Board of Health Approval for Operation_____________________________ ___________

(Signature) (Date)

Building Permit Application # ____________ Wiring Permit Application # ____________

Board of Health Permit for Installation:_______________________________ __________

(Signature) (Date)