Boiler engineer license exam application

1 I ndividual Boiler Engin eer Li cense Examination application application Fee = $ IN BOX FOR OFFICE USE ONLY SELECT THE license YOU ARE APPLYING FOR: Chief A Class 1A C las s 2 A C las s Chief B Class 1B C las s 2 B C las s Chief C Class 1 C Class 2 C Class Spec ial E ngi neer H istorical Boiler E ngi neerAccount Number 632448 STK B42 BOILLIC Check Number Amount Paid PCK CCK MODLI Deposit Date NOTICE: Pursuant to M innesota Statute , checks returned for non payment will be charged a $30 service charge and may s ubject the issuer to additional civil pe nalti this a license exam retest?

2 YES NO If YES, submit application form and fee. Affidavit form is not required. PRINT IN INK OR TYPEMAKE A COPY OF THIS application FOR YOUR RECORDS application NUMBER: license NUMBER: Boiler license NUMBER In the space below, enter minnesota Boiler engineer lic ense number(s) currently held, if ap plicable. (An applicant for a Special engineer license has no number to enter.)AFFID AVIT OF O PERATING EXPERIENCE No a ffi davit required Spec ial engineer Historical Boiler eng ineer affidavit Boile r eng ineer license affi davit (al l chief c lass, 1st class, and 2ndclas s license applications require an affidavit) MILITARY OPERATING EXPERIENCE Appli cants may apply their Boiler operating ex perience in the Ar med Forces toward qualifying fo r a boi ler l icens e.

3 DD-214 and s upporting do cumentat ionMINNESOTA Boiler engineer license NO. yes minnesota De partm ent of Labo r and Ind ustry Constructio n Codes and Li censin g Div ision Licensing / Boiler Box 64217 St. Paul, MN 55164-0217 Email: Phone: (651) 284-5031 PAID application FEE IS NOT REFUNDABLE CASH IS NOT ACCEPTED BY MAIL OR WALK-IN MAKE CHECK OR MONEY ORDER PAYABLE TO: minnesota department OF labor & industry The information you as an indivi dua l prov ide in this app lication will be used by department of labor & Indust ry st aff members to determine if yo u meet the department s reg ist ration requ irements.

4 Mi nne sota Statute 270 C. 72 S ubd. 4 requ ires yo u to prov ide you r social security number on this applicati on. The other information is being requested fo r purposes of pro cessing you r application . With the exception of you r S ocial Security, yo u are not l egal ly requ ired to supp ly th e requested data on this app lic ation; however, fa ilure to prov ide the requested information may delay the pro ce ss ing of you r app lication or resu lt in the den ial of the same. Exc ept for you r name and desi gna ted address, the information yo u p rov ide on this app lication is pri vate data while the app lication is pending.

5 Di sclos ure of th is information to others ma y occu r as aut horize d or requi red b y law, including but not limited to the Attorney General s O ffice , the department of Revenue, the department of Human Serv ices, upon cour t order , and /or for the pur pose of ver ification and i nvest igati on. Onc e yo u are reg ist ered, the i nformation yo u prov ide, ot her than you r Social Security Number and non -desi gna ted address, becomes pub lic data and may be released to anyone upo n request. SOCIAL SECURITY NUMBER DATE OF BIRTH (MM/DD/YYYY) AREA CODE & PHONE NUMBER E-MAIL ADDRESS LEGAL LAST NAME SUFFIX (JR, SR, II , II I) LEGAL FIRST NAME LEGAL MIDDLE NAME RESIDENTIAL ADDRESS PUBLIC MAILING ADDRESS (if different from residential address) CITY NAME STATE ZI P CODE CITY NAME STATE ZI P CODE Is the Residential address abov e a non- desi gna ted (pri va te ) address?

6 Yes No If , t hen yo u must prov ide a designa ted (Public) mailing address. APPLICANT SIGNATURE DATE SIGNED (MM/DD/YYYY) This material can be made available in differen t forms, such as lar ge print, braille or on a tape. CC0500 Initial Boiler Engin eer license Exam application minnesota department of labor and industry Construction Codes and Licensing Division Licensing and Certification Services 443 Lafayette Road North St. Paul, MN 55155 Mailing Address: PO Box 64217 St. Paul, MN 55164-0217 E-mail: Site: : (651) 284-5031 Boiler engineer license Affidavit (Chief, First Class, and Second Class Licenses) I, , upon oath duly administered, declare that to my personal knowledge, (*chief engineer , second class engineer higher or employer) the applicant: of: operator s license number (city and state) Note: Do not use manufacturers horsepower ratings.

7 For Licensing purposes, 10 square feet of heating surface = One Boiler Horsepower, or if cannot be discerned, 67,000 btu/hr input = One Boiler Horsepower. Reference rule For high pressure A or B licenses, one year is equal to 2000 hours, reference rule , Subp. 10. minnesota Residents: may only claim operating experience gained while the applicant had a valid license . HAS ACTUALLY OPERATED A STEAM Boiler PLANT Total HorsepowerMaximum W orking Pressure (psi)From Month Day YearTO (must have end date) Month Day Yearand/or HOT WATER Boiler PLANT BTU Input/KW /HorsepowerPressureTemperatureFromMonth Day YearTO (must have end date) Month Day YearAnd (if application ) STEAM ENGINES OR STEAM TURBINEST otal HorsepowerFromMonth Day Year ToMonth Day Year Total HoursHIGH PRESSURE Total High Pressure Boiler Operation Hours From Month Day Year ToMonth Day Year Total HoursPursuant to Minn.

8 Stat. , subd. 11(b)(2), submission of a false or misleading experience affidavit or other document relating to a license application provides cause for a civil penalty of up to $10,000 as well as the suspension or revocation of the license (s) of any person involved in such a submission. *Name of engineer or Manager (required) license Number or Title (required) Work Telephone Number Employer Name where building is located. (required) Employer Address where building is located. (required)CityStateZip Code *This affidavit must be completed by a Chief engineer , 1st Class engineer , 2nd Class engineer or by a and sworn to before me on the _____day of , in the year 20 ___ by (*Signature of chief engineer , 1st class engineer , 2nd class engineer or manager) Signed (Notary Public) (Stamp) The information provided on this form is used to determine if the applicant meets the license requirements.

9 The requested information is required to process the license application . Failure to provide the requested information may delay the processing of license application or may be grounds for denying your application . Under , the information that is provided on this form, except for the applicant s name and address, is private data while the application is pending. Disclosure of this information to others may occur as authorized or required by law, including the Attorney General s Office, the department of Revenue, the department of Human Services, and/or for the purpose of verification and investigation. Once the applicant is licensed, the information becomes public data and will be part of the agency s permanent records.

10 This material can be made available in different formats, such as large print, braille or on audio. (of Applicant, if applicable)Instructions for CC0511 Boiler engineer license Affidavit minnesota department of labor and industry Construction Codes and Licensing Division Licensing and Certification Services 443 Lafayette Road North St. Paul, MN 55155 Mailing Address: PO Box 64217 St. Paul, MN 55164-0217 E-mail: Site: : (651) 284-5031 Instructions for Completing the Boiler Affidavit The original affidavit(s) must be fully completed in ink, notarized and returned to our office with the approp riat e exam fees and application .