42-180 (7) CHARLES D. BAKER
GOVERNOR JOHN C.CHAPMAN
UNDERSECRETRY OF
Commonwealth of Massachusetts CONSUMER AFFAIRS AND
KARYN E. POLITO BUSINESS REGULATION
LIEUTENANT GOVERNOR Division of Professional Licensure
JAY ASH 1000 Washington Street • Boston • Massachusetts • 02118 CHARLES BORSTEL
COMMISSIONER,DIVISION OF
SECRETARY OF HOUSING AND PROFESSIONAL LICENSURE
ECONOMIC DEVELOPMENT
October 25, 2018
Smith Vocational Iligh School
80 Locust Street
Northampton,IMA 01060
Attn: Armand Lamour
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RE. Smith Vocational High SchoolHabitat for Humanity-125, 129, 133 Glendale Road-
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Northampton 1
Dear Armand Lamour
Your application to perform Plumbing for your school at the above mentioned location has been
approved by the Board. Work on this project shall be limited to the type of project lesson as
explained in your submitted application.
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Included in this mailing you will find a copy of the documents with the stamped approval.
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If you have any questions regarding this matter or if we may be of any further assistance,please
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do not hesitate to contact the Board Office via e-mail lam'.lemieux'u mass.gov
Sincerely,
For the B rd c
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aurent A.Lemie
Executive Director
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Massachusetts Board of State Examiners
Of Plumbers.and Gas Fitters
Cc: Larry Eldridge, Northampton Plumbing and Gas Inspector l
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TELEPHONE: (617)727-3074 FAX: (617)727-2197 TTY/TDD: (617)727-2099 http:/Iwww.mass.gov/d `
Commonwealth of Massachusetts
Division of Professional Licensure
Board of State Examiners of Plumbers and Gas Fitters
1000 Washington Street. Boston • Massachusetts • 02118-6100
PUBLIC CAREERIVOCATIONAL TECHNICAL HIGH SCHOOL PROGRAM
APPLICATION TO PERFORM PLUMBING AND/OR GAS FITTING WORK
RESIDENTIAL PROJECT APPLICATION I
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This application must be filed with the Board and Approved prior to issuance of
a plumbing or gas fitting permit by the Local Inspector.
PLEASE PRINT CLEARLY
To be filled out by the Lead Plumbing&Gas Fitting Instructor
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Name of School: Submi Lal jDate:
smlt'a lt-10"'a�I-Ot7'41 I
Address: Cit /Town: State: Zip Code.
90 tocu S4" /1/0 AW oxoco
Name of Plumbing and Gas Fitting Department Head: Phone&Extension:
Scot a}-e.rSD
Name of School Instructor who will be the Plumbing/Gas Fitting Permit Holder of Record for this Project: Master License Number:
Department Head email: School Instructor email:
S ' r l �m L,P !/16 I
ALL OF THE FOLLOWING ITEMS MU E INITIALED BY THE SCHOOL INSTRUCTOR/PERMIT HO R OF 1
RECORD.IF LEFT BLANK.THE APPLICATION WILL BE DEEMED INCOMPLETE AND WILL NOT BE ACCEPTED.
1.1 have included a copy of the lesson plan,signed by my local school administration with this application INITI L BELOW
2.All of the plumbing and/or gas fitting students performing work on this project shall be under the direct supervision INITIAL BELOW
of Board certified instructors. All instructors are Identified on this form.Any changes must be approved by the Board. �L
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3.1 certify that all plumbing and/or gas fitting performed on this project shall be limited to the work specified in the INITIAL BELOW
Included lesson plan. L
4.1 understand and agree that each Board certified plumbing and/or gas fitting instructor is limited in the number of INITIAL BELOW
G5students that they may supervise in compliance with Board designated instructor to student ratios. )9z-
5.
.1 certify that no plumbing and/or gas fitting work has been performed by any students on this project to date, INITIAL BELOW N
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6.1 certify that I shall file a permit with the local inspector of plumbing and gas prior to work commencing and shall be INITIAL BELOW
responsible for ensuring that required rough and final inspections take place.
7.1 certify that I have read and fully understand the current Board Vocational School Policy for School Projects INITIAL BELOW s
B.I certify that all students taking part in this project have completed a minimum of 110 hours of the Board approved INITIAL BELOW
Tier Program for licensure. '04
I certify,under pains and penalties of perjury that the in rmation on this form is true and accurate.
Signature of Applicant � Date: /
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LESSON - PROJECT INFORMATION
PLEASE PRINT CLEARLY
Name of party for whom the work is to be performed:
vInA/l,'�-
Address: City/Town: State: Zip Code:
lne� 53" �oren /''I D/D�o i
Location where work is to be performed if different than above:
Address: City/Town: State: Zip Code:
la s' r7, / Iva /40 01066
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New: Renovation:
Please check the boxes for other Licensed Trade programs within your school which will be working on the project at this location:
Electrical: rte( Pipe Fitting: ❑ Refrigeration: Sheet Metal: f
other: Yee S-F1
Brief description of plumbing work related to this project:
+�o f #/�,5� iS a Sf%�l� 6u,�/f /10 p.. Sa fierce i,✓.'// De U/.�ers/�
�of s is 9 �' r��r���1e'�d/dam- fiG�lfJ�S sa CdnArc.lb�Un d Y' "
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Brief description of gas fitting work related to this project:
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Explain how this project lesson will benefit the students of your program:( 1
Sfude.4 i-s Inti 1l /eG(,n -;qe JAghle Br A zuakw D�'A6,2 siva aF,'PA..
f'CS , 03 tJ v ' e a GJ tar Sv `mss
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What grades will be participating in this project?
Freshman: El Sophomore: El Junior: Senior:
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What is the projected number of plumbing and/or gas fitting students who will be participating In this project?
Please list the names and Master license numbers of certified plumbing/gas fitting instructors who will be participating
In this project?
Name: Master License Number: 010_5
Name: firm,;) J L moor Master License Number: [50 2K
Name: / alam A011,4 5/i+ Master License Number: /b Z
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Name. Master License Number:
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OFFICIAL BOARD USE ONLY
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BOAR TAMP
SPS OF
APPROVED B
APPROVEDSUBJECT TO RULES
AND REGULATIONS
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CHECKED BY �� O
U) DATE /o �� G?
APPROVAL DATE: 2S �`� �O FOR THE BOARD Q)
��. PLAN EXAMINER
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