Revised May 2017
New Installation ( ) Annual Inspection ( )
TYPE OF PRESSURE VESSEL CHECK ONE:
Air Tank ( ) Inspection Fee - $50.00
Boiler, Cast Iron Sectional ( ) Inspection Fee - $50.00
Boiler, Other: ( ) Inspection Fee - $100.00
Refrigeration/Air Conditioning – 20 ton capacity ( ) Inspection Fee - $60.00 (minimum)
$2 fee for each additional 20 tons Additional Tons ______ Additional Fee $_______
(Maximum inspection fee for Refrigeration/AC is $300)
Check # __________________ Total Amount Due/Enclosed: $_______._____
*
* AFTER INSPECTION THE DEPARTMENT WILL INVOICE A MANDATORY $50.00 CERTIFICATE PROCESSING FEE **
CERTIFICATES WILL NOT BE ISSUED UNTIL PAYMENT IS RECEIVED
Manufacturer: __________________________________ Year: ________________________
National Board #__________________ Mass Tag #__________________ Not to exceed ________________lbs/sq in
In compliance with M.G.L., Chapter 146 and application regulations, the undersigned applies for the required inspection.
________________________________________________________ _______________
Signature of Owner or Authorized Representative Date
OWNER/USER INFORMATION (please print)
NAME: ___________________________________________________________________________________
ADDRESS: ___________________________________________________________________________________
___________________________________________________________________________________
CONTACT PERSON: ______________________________________________________________________________
TELEPHONE NUMBER: ____________________ PAYMENT EMAIL: ____________________________________
LOCATION OF PRESSURE VESSEL (please print)
NAME: ___________________________________________________________________________________
ADDRESS: ___________________________________________________________________________________
___________________________________________________________________________________
CONTACT PERSON: ______________________________________________________________________________
TELEPHONE NUMBER: ____________________ CERTIFICATE EMAIL: ________________________________
Mail Application and Payment to:
Commonwealth of Massachusetts – Boiler Inspection Program
P. O. Box 417599
Boston, MA 02241-7599
Enclose a check or money order made payable to: The Commonwealth of Massachusetts.
COMMONWEALTH OF MASSACHUSETTS
D
EPARTMENT OF FIRE S
ERVICES
INSPECTION APPLICATION - PRESSURE VESSEL DATA
Department of Fire Services, Boiler & Pressure Vessel Program
, 1 State Rd. Stow, MA 01775-1025
BPV-030
Please use a separate application for each device to be inspected
Phone (978) 567-3780
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signature
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