Gas Equipment Permit Application

Newbury Fire Department
PO Box 373, Newbury NH 03255
Permit to Install and Operate Gas Equipment

Click here to download a printable version of this form to mail to the Newbury Fire Department

To the Chief of the Fire Department:

The undersigned hereby applies for a permit to install and operate gas burning or wood burning equipment in compliance with R.S.A. 153.5 (State Fire Code) and NFPA 54 (Fuel Gas Code), NFPA 58 (Liquified Petroleum Gas Code), NFPA 110 (Standard for Emergency & Standby Power), as follows:

Address:

Address # Posted

Map and Lot Number

Type of Occupancy:

Resident Other

Number of Stories

Owner:

Contact Phone*:

Address of Owner:

Contact Email*:

Occupant's name:

Does the building have Smoke & Carbon Monoxide detectors?

Make, Model & Serial Number of Gas Equipment:

Size and Location of Propane Tank

Name of Installer

NH License #

Business Name:

Phone:

E-Mail:

Address:

Town:

Zip:

State: