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STATE OF IOWA Division of Labor - Boilers (Office of the Chief Information Officer)

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STATE OF IOWA
ADVANCE NOTICE OF
BOILER INSTALLATION
IOWA
DEVELOPMENT
Smart. Results.
Division of Labor - Boilers
1000 East Grand Avenue
Des Moines, Iowa 50319-0209
PHONE: 515-281-6533
FAX: 515-242-5076
WEB: www.iowaworkforce.org
Instructions:
1. IowaCodeSection89.6requiresthisformbeledwiththeLaborCommissioneratleast10days
priortoinstallation.
2. Yourboilerorpressurevesselmustpassinspectionpriortooperation.
3. Notifyyourinsurancecompanyofthisinstallationimmediatelyifyouhaveboilerinsurance.
4. Tominimizecostlydelays,pleasereviewtheapplicablerulespriortoinstallation.Therulesare
availableonourwebsiteatwww.iowaworkforce.org/labor/boiler_inspection_.htm or contact the
ChiefBoilerInspectorat515-281-8064.
OWNER-USER OBJECT LOCATION
Name Name
Street Address Street Address
City,State,Zip City,State,Zip
Phone # Phone #
Manufacturer YearBuilt InstallationType
rNew rReinstalled
InstallationDate
BoilerUse
SpecicOn-SiteLocation
i.e.,UtilityRoom
Fuel Method of Firing
Code Stamp(s)
rA rS rUrHLW
rM rE rH rOther
_______________________
__________________________________
SalesRep
__________________________________
Phone #
Doesboilerreplaceexistingone?
rYes rNo
Ifyes,whatisoldJurisdiction#
______________________________
Comments:
_________________________________________________________________________________
_______________________________________ ______________________________ _________
Owner’s Signature Owner’s Name (print) Date
Istheownerusingaboilerinsuranceinspectionservice?rYes rNo (Ifyes,pleasenotifyyourinsurancecompanyimmediately)
BoilerInstallationReport(Boiler-Clerical10-24-07)309-6706(06-08)
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STATE OF IOWA Division of Labor - Boilers (Office of the Chief Information Officer)

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Completed 20 July 2020

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