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Gas Contractor Declaration of Compliance
FAX Declaration to 604-467-7461 OR E-mail to
inspectionrequests@mapleridge.ca OR send via regular mail
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City of Maple Ridge REVISED 2016-10-18
11995 Haney Place, Maple Ridge, BC V2X 6A9 Tel: 604-467-7311 Fax: 604-467-7461
Inspection Requests: inspectionrequests@mapleridge.ca Web Site: www.mapleridge.ca Inquiries at: permits@mapleridge.ca
FINAL GAS INSPECTIONS CAN ONLY BE SCHEDULED BY SUBMITTING THIS FORM. PHONE REQUESTS WILL NOT BE ACCEPTED.
INSTALLATION (PLEASE PRINT CLEARLY)
Permit Number:
Installation Name:
Location of work site: Address: (Unit/Suite #; Civic #; Street Name; City; Postal Code)
REGISTERED GAS CONTRACTOR (PLEASE PRINT CLEARLY)
Licensed Gas Contractor(GC) Name:
License No.:
Contact Phone #: Fax: E-mail:
Complete Mailing Address: (Unit/Suite #; Civic #; Street Name; City; Postal Code)
DECLARATION
□ FINAL
Gas Safety Representation(GSR) No.: GSR Class:
“I a gas safety representative for the above licensed contractor, hereby
declare that the gas installation authorized under the above permit has been installed to comply with the Safety
Standards Act and Regulations of British Columbia and has been left in a safe operating condition. Furthermore, all
appliances have been sized and installed as per permit.”
Gas Safety Representation (GSR) Signature:
Date:
YYYY MM DD
□ Gas work complete without Installation Permit in accordance with the provisions of the BC Safety Standards Act
□ Deficiencies of: Date: YYYY
MM DD Have been corrected.
OFFICE USE ONLY:
Installation as noted above has been accepted on the basis
of the Qualification of the Gas Contractor’s Field Safety
Representative.
Name: (Please print)
Date: YYYY
MM DD Gas Safety Officer Signature.