Fillable Form 87-12 - REV 5-15 - Limited Plumbers License Application LPL - 1

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Form 87-12 - REV 5-15 - Limited Plumbers License Application LPL - 1

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The Form 87-12 - REV 5-15 - Limited Plumbers License Application LPL - 1 form is 2 pages long and contains:

  • 3 signatures
  • 7 check-boxes
  • 18 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town of Huntington

BROWSE TOWN OF HUNTINGTON (NY) FORMS

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TOWN OF HUNTINGTON
APPROVED:
NAME: DATE OF BIRTH:
ADDRESS:
TELEPHONE:
LAWN IRRIGATION SYSTEMS
AUTOMATIC FIRE EXTINGUISHING SYSTEMS
FIRE SPRINKLERS
LIQUID PROPANE GAS INSTALLATIONS
I feel that my qualifications (i.e. education, training, work experience) which provide eligibility are as follows:
1.
2.
3.
STATE OF NEW YORK
COUNTY OF SUFFOLK
SS:
}
I here declare, under oath, that I fully understand and have answered all of the above questions truthfully; that I am the person
who is to be examined if examination is required and that I have read and understand the Plumbing Licensing Ordinance of the
Town of Huntington.
Signature of Applicant
Sworn to me this day
of , 20
Notary Public
SEE REVERSE SIDE FOR CONFIRMATION OF QUALIFICATIONS
(OVER)
FORM 87-12 - REV 5/15 - pg.1
EMAIL:
This Application is submitted for a limited license in the field that I have checked below
THIS DECLARATION TO BE COMPLETED AND SIGNED BY THE PERSON(S) WHO CAN ATTEST TO THE
QUALIFICATIONS STIPULATED BY THE APPLICANT ON THE REVERSE SIDE OF THIS APPLICATION
TRADE/VOCATIONAL SCHOOL
Name of School
Name of Authorized Person (Please Print) Signature of Authorized Person
APPRENTICESHIP
Name of Company
Name of Authorized Person (Please Print) Signature of Authorized Person
LICENSED PLUMBER
Licensed By
License Number Signature
FORM 87-12 - REV 5/15 - pg.2
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Form 87-12 - REV 5-15 - Limited Plumbers License Application LPL - 1

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Completed 13 July 2020

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