Form DSFM115 "Request & Payment for New Hampshire Labels" - New Hampshire

What Is Form DSFM115?

This is a legal form that was released by the New Hampshire Department of Safety - a government authority operating within New Hampshire. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2019;
  • The latest edition provided by the New Hampshire Department of Safety;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DSFM115 by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Safety.

ADVERTISEMENT
ADVERTISEMENT

Download Form DSFM115 "Request & Payment for New Hampshire Labels" - New Hampshire

Download PDF

Fill PDF online

Rate (4.3 / 5) 21 votes
STATE OF NEW HAMPSHIRE DEPARTMENT OF SAFETY
Division of Fire Safety
OFFICE OF THE STATE FIRE MARSHAL
Paul J Parisi, State Fire Marshal
Mailing Address: 33 Hazen Drive, Concord, NH 03305
603-223-4289, 603-223-4295 (fax)
REQUEST & PAYMENT FOR NEW HAMPSHIRE LABELS
_____________________________________________________________________
MANUFACTURER TO COMPLETE:
CORPORATE NAME: ______________________________________MGF ID#__________________________________
FACILITY NAME: __________________________________________________________________________________
MAILING ADDRESS: _______________________________________________________________________________
CITY: ________________________________________________ STATE:__________ ZIP CODE:_________________
AUTHORIZED AGENT: _____________________________________________________________________________
N.H. STREET ADDRESS AND TOWN OF MODULES DESTINATION:__________________________________________
QTY OF MODULES FOR N.H. ADDRESS LISTED ABOVE: _______________________________________
Per NH Saf-C 3309.11(a) The department shall charge a fee of $100.00 for each state label for the first 4 residential modules and $50.00 for each
additional module, up to a maximum of $2,000.00 per residential structure.
(QTY REQUESTED FOR RESIDENTIAL SHALL BE PER RESIDENTIAL STRUCTURE AT THE ADDRESS LISTED ABOVE)
CHECKS MUST BE MADE PAYABLE TO: THE STATE OF NEW HAMPSHIRE
LABELS REQUESTED (Qty 1 - 4) (Residential):_________________ X $100.00 EACH = $__________________________
LABELS REQUESTED (Qty 5 and up) (Residential):_______________X $ 50.00 EACH = $__________________________
LABELS REQUESTED (Non-Residential): ______________________X $100.00 EACH = $_________________________
CHECK NUMBER___________________DATED _______________IN THE AMOUNT OF $________________________
___________________________________________________________________________________________________________
Third Party to Complete:
TPA ASSIGNMENT OF LABEL NUMBERS
The following un-issued label numbers are assigned to the specific facility identified above:
LABEL # __________________ THRU & INCLUDING #__________________=_____________# OF LABELS.
AUTHORIZED REPRESENTATIVE: ________________________________________DATE:_______________
INSTRUCTIONS
MANUFACTURER: Please mail a copy to your TPA with your payment. Your check must be made
payable To: The State of New Hampshire.
DSFM 115 (Rev 11/19)
STATE OF NEW HAMPSHIRE DEPARTMENT OF SAFETY
Division of Fire Safety
OFFICE OF THE STATE FIRE MARSHAL
Paul J Parisi, State Fire Marshal
Mailing Address: 33 Hazen Drive, Concord, NH 03305
603-223-4289, 603-223-4295 (fax)
REQUEST & PAYMENT FOR NEW HAMPSHIRE LABELS
_____________________________________________________________________
MANUFACTURER TO COMPLETE:
CORPORATE NAME: ______________________________________MGF ID#__________________________________
FACILITY NAME: __________________________________________________________________________________
MAILING ADDRESS: _______________________________________________________________________________
CITY: ________________________________________________ STATE:__________ ZIP CODE:_________________
AUTHORIZED AGENT: _____________________________________________________________________________
N.H. STREET ADDRESS AND TOWN OF MODULES DESTINATION:__________________________________________
QTY OF MODULES FOR N.H. ADDRESS LISTED ABOVE: _______________________________________
Per NH Saf-C 3309.11(a) The department shall charge a fee of $100.00 for each state label for the first 4 residential modules and $50.00 for each
additional module, up to a maximum of $2,000.00 per residential structure.
(QTY REQUESTED FOR RESIDENTIAL SHALL BE PER RESIDENTIAL STRUCTURE AT THE ADDRESS LISTED ABOVE)
CHECKS MUST BE MADE PAYABLE TO: THE STATE OF NEW HAMPSHIRE
LABELS REQUESTED (Qty 1 - 4) (Residential):_________________ X $100.00 EACH = $__________________________
LABELS REQUESTED (Qty 5 and up) (Residential):_______________X $ 50.00 EACH = $__________________________
LABELS REQUESTED (Non-Residential): ______________________X $100.00 EACH = $_________________________
CHECK NUMBER___________________DATED _______________IN THE AMOUNT OF $________________________
___________________________________________________________________________________________________________
Third Party to Complete:
TPA ASSIGNMENT OF LABEL NUMBERS
The following un-issued label numbers are assigned to the specific facility identified above:
LABEL # __________________ THRU & INCLUDING #__________________=_____________# OF LABELS.
AUTHORIZED REPRESENTATIVE: ________________________________________DATE:_______________
INSTRUCTIONS
MANUFACTURER: Please mail a copy to your TPA with your payment. Your check must be made
payable To: The State of New Hampshire.
DSFM 115 (Rev 11/19)