Fillable Boil.adv .ins .notice 4 (Office of the Chief Information Officer)

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Boil.adv .ins .notice 4 (Office of the Chief Information Officer)

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[
Iowa Division of Labor
Boiler and Pressure Vessel Safety
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-725-5609/515-725-5610
Fax: 515-242-5076
boilers@iwd.iowa.gov
www.iowaboilers.gov
Advance Notice of Boiler Installation
Date Received:
Object #:
Inspection Date:
222-004
02.04.2020
Owner information
Name
Phone number
Fax number
Address
City
State
Zip
Will a boiler insurance inspection service be used? Yes No If yes, notify the boiler insurance company immediately.
Name of insurance company:
Object location information
Name
Phone Number
Address
City
State
Zip
Manufacturer
Year built
Installation type:
New Reinstallation
Installation date
Does boiler replace existing boiler? Yes No If yes, old state ID#:
Boiler use
Specific on-site location
Fuel
Method of firing
Code stamp: A S U HLW M E H Other:
Sales Representative
Phone number
Comments:
I certify that the information on this form is true and accurate to the best of my knowledge.
Name of individual completing form Business name Phone number
Email address Signature Date
Instructions
The boiler or pressure vessel must pass inspection prior to operation.
Iowa Code Section 89.6 requires this form be filed with the Labor Commissioner at least 10 days prior to installation.
Send the completed application to the address above. Prior to installation review the application rules at
www.iowaboilers.gov.
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities.
For deaf and hard of hearing, use Relay 711.
FOR OFFICE USE ONLY
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Boil.adv .ins .notice 4 (Office of the Chief Information Officer)

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Completed 20 July 2020

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