Free Request for Boiler Repair/Alteration Inspection - Arizona


File Size: 183.9 kB
Pages: 1
Date: May 14, 2008
File Format: PDF
State: Arizona
Category: Workers Compensation
Word Count: 362 Words, 2,534 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.ica.state.az.us/forms/adosh/requestBoilerRepair.pdf

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Preview Request for Boiler Repair/Alteration Inspection
The Industrial Commission of Arizona Division of Occupational Safety and Health BOILER SAFETY SECTION 800 West Washington Street Phoenix AZ 85007-2922

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SEND BY FAX: 602-542-1614

REQUEST FOR INSPECTION OF A NON-WELD ALTERATION OR REPAIR OF A BOILER OR FIRED PRESSURE VESSEL An owner, user or licensed contractor must request an Inspection prior to performing an alteration or repair of a boiler or a fired pressure vessel in the State of Arizona in accordance with R20-5-404.B, and R20-5-406. The following provisions must be met or your request will not be accepted: 1. 2. 3. 4. The boiler or fired pressure vessel must be constructed in a manner which meets the standards of the Arizona Boiler Rules: R20-5-404. The owner, user or licensed contractor shall have on-site theManufacturer's Data Report for the boiler and/or fired pressure vessel, and any other Manufacturer's manuals/documents pertinent to the contemplated alteration or repair. Non-weld alterations or repairs shall be performed by an installer holding a current contractor's license issued pursuant to Chapter 10, Title 32 32-1122 of ARS, which authorizes the licensee to perform boilers or fired pressure vessel work. This Inspection Request is not for welded alterations or repairs. Alteration or repair of a boiler or fired pressure vessel involving welding shall be performed by an organization accredited by the National Board of Boiler and Pressure Vessel Inspectors as stipulated in R20-5-404B. PHONE STATE STATE ZIP CODE ZIP CODE TENTATIVE START-UP NO

OWNER OR USER MAILING ADDRESS CITY BOILER/FIRED PV LOCATION CITY TENTATIVE ALTERATION/REPAIR DATE

DOES OWNER/USER CARRY BOILER/PRESSURE VESSEL INSURANCE? YES IF YES, WHO IS THE INSURANCE CARRIER'S NAME (NOT AGENT'S NAME) PURPOSE OF ALTERATION/REPAIR:

Object Description Boiler/Wtr.Htr./FPV

Mfg's Name

AZ Number

NB Number

Note: above information is found on manufacturer's data plate and/or Manufacturer's Data Report AZ: Arizona issued number, NB: National Board number

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: Acceppted_______________Date_______________ Denied__________________Date_____________

Signature: ____________________________________________ Title______________________________________