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Board of State Examiners of Plumbers and Gas Fitters ... - PSI

Board of State Examiners of Plumbers and Gas Fitters ... - PSI

Commonwealth

Commonwealth of Massachusetts Office of Consumer Affairs DIVISION OF PROFESSIONAL LICENSURE Board of State Examiners of Plumbers and Gas Fitters 1000 Washington St., 7 th Floor Boston, Massachusetts 02118 VERIFICATION OF SCHOOL AND SHOP HOURS TO THE BOARD OF STATE EXAMINERS OF PLUMBERS AND GAS FITTERS: In connection with my application for a journeyman or master plumbers, journeyman Gas Fitter or LP Installer license, I submit the following verification of schooling: Name of Applicant: (Type or Print Clearly) Address Signature of Applicant Date THE FOLLOWING IS TO BE COMPLETED BY SCHOOL OFFICIALS Subject to the rules set forth in Section 4 of Chapter 142 of the General Laws, I subscribe to and vouch for the statement made by: Name of Applicant: (Type or Print Clearly) Address Name of School Address From Date of Enrollment To Date of Completion of Course or Graduation During that time, the student successfully completed the following which meets the requirements of 248 CMR 11.06 hours of advanced plumbing and gasfitting theory for Master Plumber Licensure hours of basic plumbing and gasfitting theory for Journeyman Plumber Licensure hours of basic gasfitting theory for Journeyman Gas Fitter Licensure hours of basic theory for LP Installer Licensure As a full time day student who graduated with a plumbing certificate, the student successfully completed: hours of shop under the supervision of a licensed plumber and obtained hours of theory Name of Designated School Official – Type or Print Title Signature of Designated School Official Date Name of Plumbing or Gas Fitting Instructor – Type or print Master License Number Signature of Plumbing or gas Fitting Instructor School Phone Number G

Commonwealth of Massachusetts Office of Consumer Affairs DIVISION OF PROFESSIONAL LICENSURE Board of State Examiners of Plumbers and Gas Fitters 1000 Washington St., 7 th Floor Boston, Massachusetts 02118 STATEMENT OF EXPERIENCE FOR GAS FITTERS Erasures, Mark Overs or White Outs are Unacceptable Type or Print Name Clearly First Middle Last Residence Number Street City or Town Zip Code Apprentice Gas Fitter Registration Number and Date of Issue Number Date of Issue EMPLOYERS STATEMENT This is to certify that: Registered Gas Fitter apprentice performing supervised gasfitting full time from: was employed by me as a Month/Day/Year To Month/Day/Year (to present is unacceptable) Company or Corporation Name Master License Number and Date Originally Issued Business Address Street City or Town Zip Code Phone Can you produce Social Security Records for this person? Yes No If you checked NO in the box above, please explain As the employer I hereby certify that the above statements are true and are made subject to the penalties of perjury. In addition, I certify that for the entire time listed above, the applicant worked for me as an apprentice plumber and not as an independent contractor or a subcontractor performing non-Gas Fitter work. Signature of Employing Master Gas Fitter PHOTOSTATS OF THESE SHEETS ARE UNACCEPTABLE H

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