Fillable Boiler License Application, Classes 1-6 (Oregon)

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Boiler License Application, Classes 1-6 (Oregon)

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The Boiler License Application, Classes 1-6 (Oregon) form is 6 pages long and contains:

  • 2 signatures
  • 16 check-boxes
  • 120 other fields

Country of origin: US
File type: PDF

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Page 1
440-2488 (5/08/COM)
Boiler License Application, Classes 1-6
Department of Consumer & Business Services
Building Codes Division • 1535 Edgewater St. NW, Salem, Oregon
Phone: 503-373-1268 • Fax: 503-378-2322
Web: bcd.oregon.gov
Mail application with payment to:
DCBS Fiscal Services
P.O. Box 14610
Salem, OR 97309-0445
Important: Read the application instructions before completing this form. Please complete all steps before
submitting your application and refer to the checklist at the end of this form.
STEP 1 APPLICANT INFORMATION (please print)
Last
First
Name:
Address (street or P.O. Box):
City:
State:
ZIP:
Phone:
- -
Fax:
- -
E-mail:
Social Security number (Required, ORS 25.785):
– –
Your Social Security number is required for BCD licenses, certifications, and registrations according to ORS 25.785, ORS 305.385, 42
USC § 405 (c)(2)(C)(i), and 42 USC § 666(a)(13). Failure to provide this information will be basis for application refusal. Your SSN may
be shared with other authorities only for tax-administration purposes and child-support enforcement (including identification).
STEP 2 PREVIOUS LICENSES
List all individual licenses that you hold or have held in Oregon.
List license(s):
STEP 3 TEST LOCATION
Please refer to the enclosed list or our Web site (http://www.cbs.state.or.us/external/bcd/licensing.html#loc) to choose a test
location.
Preferred testing location:
STEP 4 TYPE OF APPLICATION (choose one)
Class 1 ...............................................................
$ 82.50
Class 5 ...............................................................
$ 82.50
Class 2 ...............................................................
$ 82.50
Class 5-A...........................................................
$ 82.50
Class 3 ...............................................................
$ 82.50
Class 5-B...........................................................
$ 82.50
Class 4 ...............................................................
$ 82.50
Class 6 ...............................................................
$ 82.50
70311/1001
Secure fax for credit card payments:
(503) 947-2333
If paying by credit card, applicant must
sign credit card information box.
Application fees are nonrefundable.
Make check or money order payable to
Department of Consumer & Business Services.
Do not send cash.
Visa MasterCard Discover
Phone:
- -
DCBS Fiscal use only: 12104/0600
/
Credit card number
Expiration date
Name of cardholder as shown on credit card
$
Cardholder signature
Amount
440-2488 (5/07/COM) Boiler License Application, Classes 1-6
Page 2
STEP 5 EMPLOYMENT HISTORY
List your experience consecutively, beginning with your present or most recent position. Describe in detail your related
duties and responsibilities. If more space is needed to list experience, please attach additional sheets.
Verification of work experience must accompany this application for classes 3-5B. See attached instructions.
Employer’s name:
Period of employment:
Address:
From:
To:
Hours worked per week:
Phone:
- -
Position/title:
Supervisor’s name:
Describe work performed:
Employer’s name:
Period of employment:
Address:
From:
To:
Hours worked per week:
Phone:
- -
Position/title:
Supervisor’s name:
Describe work performed:
Employer’s name:
Period of employment:
Address:
From:
To:
Hours worked per week:
Phone:
- -
Position/title:
Supervisor’s name:
Describe work performed:
Employer’s name:
Period of employment:
Address:
From:
To:
Hours worked per week:
Phone:
- -
Position/title:
Supervisor’s name:
Describe work performed:
440-2488 (5/07/COM) Boiler License Application, Classes 1-6
Page 3
STEP 6 VERIFICATION OF WORK EXPERIENCE (Class 3-5B only)
To provide proof of your work experience, submit a Boiler Experience Verification form (440-2488A) from each of
your employers.
OR
Applicants relying on military experience must submit the following:
• Official documentation from supervising official showing the type and approximate hours of work experience
• Other reliable documentation verifying training and experience if supervisor cannot be located
STEP 7 PHOTOGRAPH OF APPLICANT
Applicants must submit a 2” x 2” passport-style photo. Write your name on the back of your photo and submit it with your
application. This photo will be printed on your license when it is issued. Please do not staple the photo.
STEP 8 CHECKLIST FOR APPLICANTS
1.
Application information complete.
2.
List of applicant’s individual licenses held in Oregon.
3.
Select a testing location. To see a list online, please visit bcd.oregon.gov for a list of proctor sites.
4.
License type selected and payment included.
5.
Employment history completed.
6.
Work experience (Form 440-2488A) from each employer (Class 3-5B only) verified.
7.
Passport-style photo (2”x2”) with applicant’s name on the back.
8.
Application signed and dated.
*Class 6 applicants must include a written statement from employer that the applicant is qualified as a welder under
ASME section IX part QW, and is qualified to that employer’s welding procedures.
STEP 9 APPLICANT AFFIDAVIT
I hereby certify that to the best of my knowledge the information on this application is complete and correct. I certify that
I have a high school diploma, GED, or equivalent. I understand that my license may be suspended, conditioned, or
revoked if I have deliberately falsified my application under ORS 455.125 and if I provide false information on this
application or cheat on a licensing examination, my application will be denied and I may not apply for any license or be
allowed to take any division-related examination for one year from the date of denial under OAR 918-001-0040. I certify
that I have read these statements and understand the terms of my license.
Name (print):
Applicant signature:
Date:
DEPARTMENT USE ONLY
Approved
Signature:
Date:
Denied
Signature:
Date:
Comments:
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signature
click to edit
440-2488 (5/07/COM) Boiler License Application, Classes 1-6
Page 4
Qualifications and Scope of Work
CLASS 1 — TRAINEE/HELPER — OAR 918-225-0691(3)
Scope:
May install, alter, or repair boilers, pressure vessels or pressure piping by any non-welded method of attachment. This
work can be done only under the direct supervision of an appropriately qualified license holder. The direct supervision
must be a ratio of one qualified license holder to one trainee. No code welding can be done under this license.
Qualifications:
• Complete application
• Pay fee
• Experience is not required
CLASS 2 — PRESSURE-VESSEL INSTALLER — OAR 918-225-0691 (4)
Scope:
May install or repair unfired pressure vessels by any non-welded method of attachment.
Qualifications:
• Complete application
• Pay fee
• Pass an examination
• Experience is not required
CLASS 3 — BUILDING-SERVICE MECHANIC — OAR 918-225-0691 (5)
Scope:
May install or repair boilers (including boiler and non-boiler external piping) and unfired pressure vessels by a
non-welded method of attachment.
Qualifications:
• Complete application
• Pay fee
• Pass an examination
• Provide 2,000 hours of verified work experience installing and repairing boilers
CLASS 4 — BOILERMAKER — OAR 918-225-0691 (6)
Scope:
May install, alter, or repair boilers and pressure vessels (excluding non-boiler external piping) by welding or other
methods of attachment.
Qualifications:
•
Complete application
•
Pay fee
•
Pass an examination
•
Provide 2,000 hours of verified work experience welding and 2,000 hours work experience doing non-
welding applications involving boiler or pressure vessels
CLASS 5 — PRESSURE-PIPING MECHANIC — OAR 918-225-0691 (7)
Scope:
May fabricate, install, alter, and repair pressure piping; install boilers and pressure vessels by attachment of piping
connections; and install, assemble and repair cast iron sectional boilers.
Qualifications:
• Complete application
• Pay fee
• Pass an examination
• Provide 2,000 hours of verified work experience performing pipe-welding or brazing on ASME B31 pressure
piping and 2,000 hours of experience performing work on pressure piping and boilers
440-2488 (5/07/COM) Boiler License Application, Classes 1-6
Page 5
CLASS 5A — PROCESS-PIPING MECHANIC — OAR 918-225-0691 (8)
Scope:
May fabricate, install, alter, or repair B31.3 process piping.
Qualifications:
• Complete application
• Pay fee
• Pass an examination
• Provide 2,000 hours of verified work experience performing pipe-welding or brazing on ASME B31.3 process
piping and 2,000 hours of work experience on pressure piping
CLASS 5B — REFRIGERATION-PIPING MECHANIC — OAR 918-225-0691 (9)
Scope:
May fabricate, install, alter, or repair B31.5 refrigeration piping.
Qualifications:
• Complete application
• Pay fee
• Pass an examination
• Provide 2,000 hours of verified work experience performing pipe-welding or brazing on ASME B31.5
refrigeration piping and 2,000 hours of work experience on pressure piping
CLASS 6 — WELDER — 918-225-0691 (10)
Scope:
May weld on boilers, pressure vessels or pressure piping while employed by an approved welding employer. Work may
only be performed under the supervision of a person licensed in CL4, CL5, CL5A, and CL5B. More than one welder may
be supervised by one qualified person under this license.
Qualifications:
•
Complete application
•
Pay fee
•
Provide a written statement from the employer that the applicant is currently qualified as a welder certified
under American Society of Mechanical Engineers (ASME) Boiler and Pressure Vessels Code Section IX
part QW, and is currently qualified to the employer’s welding procedures.
440-2488A (5/08/COM)
Boiler Experience Verification, Classes 3-5B
Department of Consumer & Business Services
Building Codes Division • 1535 Edgewater St. NW, Salem, Oregon
Phone: 503-373-1268 • Fax: 503-378-2322
Web: bcd.oregon.gov
Mail verification to:
Building Codes Division
P.O. Box 14470
Salem, OR 97309-0404
VERIFIER / APPLICANT INFORMATION
To (verifier):
Applicant’s name:
Address:
Position/title:
Phone:
- -
E-mail:
Verification of work experience is required to obtain a license in Oregon. Please return the completed form to the applicant
as soon as possible.
VERIFIED EXPERIENCE
Describe applicant’s position and type of work performed. Provide any details that might help us evaluate the applicant’s
experience. Additional sheets may be attached.
I certify that I know the applicant and have direct knowledge that the applicant was employed as follows:
Employer:
Position/title:
Period of employment:
Duties, skills, functions:
List the number of hours the applicant performed in the following categories:
Category of work
Total hours
Class 3:
Installing and repairing boilers
Class 4:
Welding involving boilers and pressure vessels
Nonwelding applications involving boilers and pressure vessels
Class 5:
Welding or brazing on pressure piping
Work on pressure piping and boilers
Class 5-A:
Welding or brazing on process piping
Work on pressure piping
Class 5-B:
Welding or brazing on refrigeration piping
Work on pressure piping
How was knowledge of the above facts acquired?
I certify that the information included in this form is true and correct.
Signature of verifier:
Date:
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Boiler License Application, Classes 1-6 (Oregon)

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Completed 21 February 2021

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