Free Application for Repair/Erection License - Tennessee

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License Number Assigned

Department of Labor and Workforce Development Boiler and Elevator Inspection Division 220 French Landing Drive Nashville, TN 37243 (615) 741-2123 or (888) 629-2895 (615) 532-1469 Facsimile

State of Tennessee

APPLICATION FOR LICENSE TO ENGAGE IN THE ERECTION, REPAIR, AND/OR ALTERATION OF BOILERS AND PRESSURE VESSELS IN THE STATE OF TENNESSEE State of Tennessee Board of Boiler Rules Attn: Chief Boiler Inspector 220 French Landing Drive Nashville, TN 37243 Date

I

Applicant's Name Company Name

, representing , am applying

for a license to engage in the erection, repair, and/or alteration of boilers and pressure vessels in the State of Tennessee. I/We enclose herewith a check for $75.00 payable to the Department of Labor and Workforce Development, to cover application and license fee. 1) Enter name and location address of Firm or Corporation as shown on the National Board and A.S.M.E Certificates of Authorization, please include telephone number, fax number and email address (where applicable).
Company Name:

Street Address: City: Telephone: Fax: Email Address: State: Zip:

LB-0386 (REV 03-07)

RDA 0093

2) Enter mailing address information if different than location address

Name:

Mailing Address: City: Telephone: Fax: Email Address: State: Zip:

3) What is the name and title of the individual within your company responsible for your Quality Control program?
Name: Title:

4) Does your company possess a repair license from any other state or jurisdiction?
If yes, please list the state or jurisduction below or attach a copy of the license(s)

YES

NO

5) Has your company ever possessed a license from this division?

YES

NO
Tennessee License Number

6) Has your company ever been denied a license from a state or jurisdiction?

If yes, please indicate the state or jurisdiction, and the reason for denial on a seperate letter to the Board.

YES

NO

7) Does your company possess a Mechanical Contractors License issued by the State of Tennessee? YES NO If yes, indicate TN Contractors Number

It is a requirement by State law and the Tennessee Department of Commerce and Insurance that any erection, installation, repair, or alteration to a boiler or pressure vessel within the State of Tennessee that is in excess of $25,000, the company involved in the erection, installation, repair, or alteration must possess a Mechanical Contractors License issued by the Department of Commerce and Insurance, Licensing Contractors Board.

8) Has your company ever been denied a contractors license or Certificate of Authorization, or had either suspended or revoked, by Tennessee, the A.S.M.E., National Board, or any other state or jurisdiction? YES NO
If yes, please indicate the state or jurisdiction, and the reason for denial, suspension or revocation on a seperate letter to the Board.

9) Are you and your company familiar the following documents? a) Tennessee Code Annotated (T.C.A.), Title 68, Chapter 122 (Tennessee Law) b) Tennessee Board of Boiler Rules and Regulations (Chapter 0800-3-3) c) A.S.M.E. Construction Codes d) National Board Inspection Code (NBIC) the State of Tennessee? YES YES YES YES NO NO NO NO

10) Does your company intend to engage in the erection of boilers and/or pressure vessels within
If so, attach a copy of your A.S.M.E. Certificates of Authorization and indicate which stamps your company possesses and their expiration date(s).

YES

NO

S PP A Expiration Date(s)

E

M

H

HLW

U

U2

U3

N

NA

NPT

11) Does your company intend to engage in the... a) Repair of boilers and/or pressure vessels within the State of Tennessee? b) Alteration of boilers and/or pressure vessels within the State of Tennessee? National Board Certificate Expiration Date Certificate Scope Shop Only Field Only Shop and Field YES YES NO NO

If so, attach a copy of your National Board Certificate of Authorization and indicate its expiration date and scope of certificate.

12) Who is your company's Authorized Inspection Agency of record? AFFIDAVIT State of County of being duly sworn, states that he or she is the of , and that the representations and statements made in the foregoing Application are true to his or her own knowledge as of the date of this Affidavit. Signature Sworn to before me this day of , 20 Date

Notary Public My commission expires on the day of , 20