Free F416-058-000 charter vessel inspection - Washington

File Size: 92.0 kB
Pages: 1
Date: April 27, 2005
File Format: PDF
State: Washington
Category: Government
Author: Forms Management
Word Count: 157 Words, 1,038 Characters
Page Size: Letter (8 1/2" x 11")

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Department of Labor and Industries WISHA Services Division Charter Boats PO Box 44650 Olympia WA 98504-4650

Department use only
Last inspection Last dry dock inspection License number Issue date # Passengers allowed # Crew required

Vessel's name Owner's name Owner's address (place to mail certificate) Vessel length (ft) Gross tonnage Hull construction Insurance policy # Beam (ft) City

Body of water certified to perform commercial business Phone number State ZIP+4 Year Fuel Type No. of cylinders per engine Horsepower per engine No. of shafts

Depth (main deck to keel, ft) City and state vessel built (manufacturer) Class of service (passenger, cargo) No. of engines Insurance policy issued by

Date insurance policy expires Date renewal exam due (every 5 yrs)

Licensed operator's name

License number

Date First Aid, CPR expires

Per RCW 88.04.035(1) and RCW 88.04.045(1), the above information is true and correct
Date Owner/Applicant's signature

F416-058-000 chartaer vessel inspection 6-04