Fillable Variance Pl Pre Installation (Commonwealth of Massachusetts)

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Variance Pl Pre Installation (Commonwealth of Massachusetts)

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The Variance Pl Pre Installation (Commonwealth of Massachusetts) form is 2 pages long and contains:

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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 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
VARIANCE FROM STATE PLUMBING CODE
PRE-INSTALLATION
$86.00 application fee payable to “Commonwealth of Massachusetts”
DO NOT USE THIS APPLICATION IF PLUMBING WORK HAS BEEN COMPLETED
PLEASE PRINT CLEARLY
(Section1) APPLICANT INFORMATION:
* “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 the plumbing work relevant to the information stated in (Section 5) has not yet been performed.
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):
Type of Work:
New Construction: Renovation:
(Section 2) OWNER OF THE PROPERTY WHERE THE VARIANCE IS LOCATED: (Please leave blank if information is the same as in Section (1))
(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:
Plumber’s Name (if available):
Plumbing Firm Name (if available):
Name of Plumbing Inspector:
Date Inspector was informed of this Variance Request:
Plumbing Code Section(s) Relevant to this Variance Request:
Work Phone:
Has Plumbing Work Begun at the Location of this Variance Request:
Yes: No: Date Work Began:
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Variance Pl Pre Installation (Commonwealth of Massachusetts)

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Completed 27 July 2020

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