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Class 8 - Installation & Service of LPG
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Full Company Name (Include DBA)
Full Physical Address
City
State
Zip Code
Full Mailing Address
City
State
Zip Code
Business Telephone
Provide information for the primary contact person for the license
Name
Title
Office Phone
Email
Do all service technicians work under an individual holding a Master Plumber Block certification?
-- Select One --
Yes
No
List all service technicians who install, maintain, or modify LP gas equipment
Attach list if necessary
1. Name
Certification #
2. Name
Certification #
3. Name
Certification #
4. Name
Certification #
5. Name
Certification #
6. Name
Certification #
7. Name
Certification #
8. Name
Certification #
Read and initial the following.
We have read the Kansas statutes and rules that regulate this license and will abide by them.
We understand that ALL employees have been trained to current NFPA 58 standards and have proof of training.
We understand that this license does not allow the holder to install or service LP Gas alternative fuel systems (carburetion).
We understand that this license does not allow the holder to sell LP Gas or LP Gas appliances or equipment.
We understand that ALL employees without Master Block Certification will obtain a Class 8 Installation license or work under the constant supervision of an individual holding the required Master Block Certification.
By typing my name and date below, I certify that this information is true and correct. Any false or fraudulent statement or failure to comply with the rules and regulations promulgated by the Office of the State Fire Marshal or K.S.A. 55-1812 shall be cause for suspension or revocation of the license held.
Name
Date
Title
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