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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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 ยง32-1122 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______________________________________