STATE OF NEW YORK

DEPARTMENT OF LABOR
DIVISION OF SAFETY AND HEALTH
Boiler Safety Bureau
STATE OFFICE BUILDING CAMPUS
ALBANY, N.Y. 12240

APPLICATION FOR PERMISSION TO INSTALL A SECOND>HAND BOILER

DO NOT BUY OR INSTALL BOILER UNTIL PERMISSION HAS BEEN GRANTED BY THIS DEPARTMENT

1. NAME OF COMPANY OR INDIVIDUAL DESIRING TO INSTALL THE BOILER 2. HOW LONG HAVE YOU OWNED THE BOILER?

3. BUSINESS ADDRESS CITY > TOWN > VILLAGE ZIP CODE COUNTY

4. COMPLETE STREET ADDRESS WHERE BOILER WILL BE INSTALLED

5. COMPLETE STREET ADDRESS OF PRESENT LOCATION OF BOILER 6. HOW LONG HAS BOILER BEEN AT PRESENT LOCATION?

7. NAME AND ADDRESS OF COMPANY OR INDIVIDUAL WHO OWNED BOILER BEFORE BEING PURCHASED BY YOU. (Do not Give Dealerπs Name)

8. WAS BOILER EVER INSPECTED UNDER THE BOILER CODE OF NEW YORK STATE? 9. DATE OF SUCH INSPECTION
" YES (If a certificate of Inspection was issued, complete Items 9, 10, 11, 12.) " NO (proceed to Item 14)

10. NEW YORK STATE BOILER NO.
13. FEIN AND/OR SOCIAL SECURITY NUMBER
11. CERTIFICATE ISSUED BY 12. PRESSURE
" NEW YORK STATE
" INSURANCE COMPANY ____________________________________
(Name of Insurance Company)

14. TYPE OF BOILER 15. BUILT BY 16. AGE

17. NUMBER OF SHELLS, DRUMS, OR SECTIONS 18. DIAMETER OR WIDTH 19. OVERALL LENGTH 20. FOR WATER > TUBE BOILER ONLY:
HEATING SURFACE
FT. IN. FT. IN. SQ. FT.
21. LONGITUDINAL JOINTS 22. STEAM PRESSURE REQUIRED
" LAP TYPE " BUTT TYPE " WELDED " RIVITED

ALL BOILERS MUST BE INSPECTED BY NEW YORK STATE OR

AN INSURANCE COMPANY PROVIDING BOILER INSURANCE
23. DO YOU PLAN TO CARRY BOILER INSURANCE?

" YES, Name of Insurance Company which Will Make Inspection _________________________________________________________________________

" NO, When Will Boiler be Ready for Inspection? _______________________________________________________________________________________

24. SIGNATURE OF OWNER OF BOILER OR OFFICE OF COMPANY 25. DATE

This application must be made by owner or user, or prospective owner or user of boiler, and the words ™owner or user∫ in this section shall not be construed to
mean the manufacturer or seller of a boiler. See Section 14>4.1 of the Boiler Code. Unless the above questions are clearly answered this application will not be
accepted. Forward last inspection report or certificate of inspection with application. Boilers, which do not meet or exceed the construction requirements
specified in the New York State Boiler Code will not be allowed to be installed in New York State. See Section 14>9.45 of the New York State Boiler Code.

YOU MUST LIST ALL STAMPING APPEARING ON BOILER ON REVERSE OF THIS FORM
SH>310 (5>93)