Fillable Inspector Reg Form (Commonwealth of Massachusetts)

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Inspector Reg Form (Commonwealth of Massachusetts)

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The Inspector Reg Form (Commonwealth of Massachusetts) form is 2 pages long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Commonwealth of Massachusetts
Division of Professional Licensure
Board of State Examiners of Plumbers and Gasfitters
1000 Washington Street • Boston • Massachusetts • 02118
TELEPHONE: (617) 727-3074 FAX: (617) 727-2197 TTY/TDD: (617) 727-2099 http://www.mass.gov/dpl
REGISTRATION FORM FOR PLUMBING AND GAS INSPECTORS
This form is required for all local inspectors, including assistants, deputies etc.
Last Name:
First Name:
Middle Initial:
Address:
City/Town: Zip Code:
Telephone:
Cell Phone:
Email:
License
Numbers
Journeyman Plumber
Master Plumber
Journeyman Gasfitter
Master Gasfitter
ALL OF THE FOLLOWING ITEMS MUST BE INITIALED, IF LEFT BLANK, THE FORM WILL BE
DEEMED INCOMPLETE AND WILL NOT BE ACCEPTED
I have been appointed and will be directly paid by the above city/town/inspectional district on page-2.
INITIAL BELOW
I certify that my plumbing/gas-fitting license has been continuously current for the five (5) year period
previous to this appointment.
INITIAL BELOW
I have read and accept the requirements of MGL Chapter 142, Sections 10 through 12 regarding
inspectors.
INITIAL BELOW
I have read and accept the requirements of 248 CMR 3,03 and 3.05 regarding inspectors.
INITIAL BELOW
I understand that I must file a separate form for each ciy\ty/town/inspectional district I inspect for.
INITIAL BELOW
I understand that I am required to complete 12-hours of special instructor continuing education
without exception.
INITIAL BELOW
I understand that I must notify the Board if any of the information I have provided on this form,
including if I leave this position.
I certify under the pains and penalties of perjury that the information on this form is true and accurate.
Signature of Applicant ___________________________________ Date: ___________________
This section of the form is to be filled out by the State/Municipal Appointing Authority
Unit of Government:
Date Inspector Appointed:
Position of Appointing Official or Designee:
Last Name:
First Name:
Address:
City/Town:
Zip Code:
Office Telephone:
Cell Phone:
Email:
I do hereby certify under the pains and penalties of perjury that the applicant listed on page
one of this form has been appointed
Signature _________________________________________ Date: _______________________
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Inspector Reg Form (Commonwealth of Massachusetts)

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Completed 27 July 2020

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