Commonwealth of Massachusetts
Office of Consumer Affairs
Division of Professional Licensure
Board of State Examiners of Plumbers and Gas Fitters
1000 Washington Street Suite 710 Boston MA 02118-6100
PRODUCT MODIFICATION FORM INSTRUCTIONS
1.
Use this modification form for model number and/or model name change that are currently listed on the Product
Acceptance Website. This form can also be used for cosmetic changes such as, the color, decorative trim and decorative
hardware, etc.
2.
Do not use the modification form for product changes made to any specific characteristics of the plumbing
and/or gas design components such as valves, methods of connection, components, combustion design, safety
devices etc..
3.
No fee is required for model number, or model name changes.
4.
Include with this form, an excel spreadsheet, cross-referencing the old model(s) with the new model(s).
NOTE: When submitting this form you must include a written statement from the original testing agency (NRTL)
that no additional testing is required for this modification.
If additional testing is required the Modification Form may not be used and the initial Product Acceptance Form
will be required.
PRODUCT MODIFICATION FORM
(1) MANUFACTURER’S INFORMATION
(2)
MANUFACTURER’S REPRESENTATIVE INFORMATION
By checking this box you are certifying under the pains and penalties of perjury that all of the information
entered on this page, to include attached documentation, is true and accurate, and the products listed are in
compliance with the provisions of Chapter 142 of the General Laws, 248 CMR Massachusetts State Fuel Gas and
Plumbing codes and other product applicable codes and standards..
APPLICANT NAME: TITLE:
DATE:
SIGNATURE OF APPLICANT
TELEPHONE: (617) 727-9952 FAX: (617) 727-1627 WEB:
https://www.mass.gov/orgs/board-of-state-examiners-of-plumbers-and-gas-fitters
MANUFACTURER:
DDRESS:
CITY: STATE: ZIP:
TEL: FAX: EMAIL:
POC: TITLE:
COMPANY:
DDRESS:
CITY: STATE: ZIP:
TEL: FAX: EMAIL:
POC: TITLE:
click to sign
signature
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