The Industrial Commission of Arizona Division of Occupational Safety and Health BOILER SAFETY SECTION 800 West Washington Street Phoenix AZ 85007-2922
SEND BY FAX: 602-542-1614
REQUEST FOR CERTIFICATE INSPECTION OF INSTALLATION OR REINSTALLATION OF BOILER OR FIRED PRESSURE VESSEL An owner, user or licensed contractor must request a Certificate Inspection prior to installing or reinstalling a boiler or a fired pressure vessel in the State of Arizona in accordance with R20-5-408, R20-5-404B, and R20-5-419. The following provisions must be met or your request will not be accepted: 1. The boiler or fired pressure vessel must be constructed in a manner which meets the standards of the Arizona Boiler Rules: R20-5-404 or R20-5-418 (R20-5-418 requires a variance request). 2. The owner, user or licensed contractor shall have on-site the Manufacturer's Data Report for the boiler and/or fired pressure vessel, comply with the clearances requirements stipulated in R20-5-404B3. Clearance requirements for boiler sides not requiring access may be waived, but must meet manufacturer's documented minimum clearance/installation requirements. 3. The installer holds a current contractor's license issued pursuant to Chapter 10, Title 32 §32-1122 of ARS, which authorizes the licensee to install boilers or fired pressure vessels. OWNER OR USER MAILING ADDRESS CITY INSTALLATION NAME/LOCATION CITY TENTATIVE INSTALLATION DATE STATE ZIP CODE TENTATIVE START-UP DATE NO STATE ZIP CODE PHONE
DOES OWNER/USER CARRY BOILER/PRESSURE VESSEL INSURANCE? YES IF YES, WHO IS THE INSURANCE CARRIER'S NAME (NOT AGENT'S NAME)
IS THIS OBJECT REPLACING AN EXISTING OBJECT?
IF YES, GIVE ID#(S) OF
OBJECT(S) BEING REPLACED: AZ# Vessel Description Boiler/Wtr.Htr./FPV Mfg's Name NB Number
Date of Mfg.
Note: above information is found on manufacturer's data plate and/or Manufacturer's Data Report. NB: National Board number, AZ: Arizona issued number; MAWP - Maximum Allowable Working Pressure
Name of Firm (Installer) Complete Mailing Address City: Telephone: Contact Person/Title On-site: State Fax:
State Contr. Lic. No. Zip Code Date: Telephone:
Signature: Title:________________________________ ============================================================================================ FOR OFFICE USE ONLY REQUEST: Accepted_____ Denied______ By______________________________________________Date_____________