Fill - Free fillable Commonwealth of Massachusetts Variance From State Plumbing Code Post-Installation PDF form

Commonwealth of Massachusetts

Division of Professional Licensure

Board of State Board of Examiners of Plumbers and Gas Fitters

1000 Washington Street  Boston  Massachusetts  02118-6100

TEL: 617-727-9952

FAX: 617-727-6095

TTY/TDD: 617.727.2099

http://www.mass.gov/dpl/boards/pl

VARIANCE FROM STATE PLUMBING CODE

POST-INSTALLATION

$86.00 application fee payable to “Commonwealth of Massachusetts”

THIS APPLICATION MUST BE FILLED OUT AND SUBMITTED BY A LICENSED PLUMBER

PLEASE PRINT CLEARLY

(Section1) APPLICANT INFORMATION: (Only the licensed plumber of record may complete this application)

* “Additionally, any response by the Board of Health or Health Department must be provided, however, the Board may waive this

requirement so long as the petition was made in a timely manner.”

ALL OF THE FOLLOWING ITEMS MUST BE INITIALED.

IF LEFT BLANK, THE FORM WILL BE DEEMED INCOMPLETE AND WILL NOT BE ACCEPTED.

1. I have included with this application written documentation that the local Board of Health has been petitioned

regarding this variance request.* (Variance requests for City of Boston must include petition to Inspectional Services)

Note: No Board of Health petition is required for buildings owned, used or leased by the State of Massachusetts.

INITIAL BELOW

6. I certify that I am the plumber responsible for the work outlined in (Section 5) of this variance request.

INITIAL BELOW

5. I understand that this variance request is for one instance at the location information stated in (Section 3) of this

application.

INITIAL BELOW

Date:

Applicant Name:

2. I have included all necessary supporting documentation regarding this variance request.

INITIAL BELOW

Firm Name (if applicable):

4. The unusual or extraordinary circumstance or established hardship that warrants special terms or conditions is

clearly stated in (Section 5) on the second page of this application

INITIAL BELOW

Street Address:

City/Town:

Zip Code:

Cell Phone:

Work Phone:

Email:

State:

3. I have included a non refundable check for $86.00 payable to the Commonwealth of Massachusetts.

Note: No payment is required for buildings owned, used or leased by the State of Massachusetts.

INITIAL BELOW

Title or Position with Firm (if applicable):

Plumbing License Number:

Master #: Journeyman #:

Plumbing Permit Number:

7. I certify that the work performed violates specific provisions of MGL Chapter 142 and/or 248 CMR as cited by the

inspector in writing which, I am providing to the Board.

INITIAL BELOW

8. I certify that I understand how the provisions of MGL Chapter 142 and/or 248 CMR have been violated and that I

will ensure all of my future work will conform to those requirements

INITIAL BELOW

(Section 2) OWNER OF THE PROPERTY WHERE THE VARIANCE IS LOCATED:

(Section 3) LOCATION OF VARIANCE: (Please leave blank if this information is the same as in Section (2))

(Section 4) ADDITIONAL INFORMATION:

(Section 5) VARIANCE INFORMATION: (Please explain in detail the established hardship relative to this variance request)

By checking this box - I hereby certify under pains and penalties of perjury that the information entered on this application request, including

supporting documentation, is true and accurate and is filed in accordance with Chapter 142, section 13 of the General Laws and 248 CMR, the Massachusetts

State Plumbing Code. I certify that all work performed prior to this request for a variance meets the requirements of 248 CMR and that I am only seeking a

variance for work that has not yet commenced. I also certify that I understand that this is a request for the Board to allow an exception to the requirements of

the Massachusetts State Plumbing Code and does not constitute an appeal of an inspector’s decision.

Signature of Applicant Date:

Individual Name:

Firm Name (if applicable):

Street Address:

City/Town:

Zip Code:

Cell Phone:

Work Phone:

Email:

State:

Name of proposed or current occupier of the building:

Street Address:

City/Town:

Zip Code:

Name of Plumbing Inspector:

Date Inspector was informed of this Variance Request:

Plumbing Code Section(s) Relevant to this Variance Request:

9. I certify that the non-compliant work was unintentionally non-compliant due to a condition that I could not have

reasonably foreseen.

INITIAL BELOW

9. I certify that I notified the inspector immediately when the work was discovered to be non-compliant and ceased

all non-compliant work since that time,

INITIAL BELOW

10. I certify that the non-conforming work is subject to immediate removal if the Board, in its discretion, rejects this

application.

INITIAL BELOW

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

Commonwealth of Massachusetts Variance From State Plumbing Code Post-Installation

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank Commonwealth of Massachusetts Variance From State Plumbing Code Post-Installation Form

Related forms

Fillable Commonwealth of Massachusetts Variance From State Plumbing Code Post-Installation

Fill Online, Printable, Fillable, Blank Commonwealth of Massachusetts Variance From State Plumbing Code Post-Installation Form

Related forms

First 20 documents completely FREE!