Form ADOSH ICA2222 "Request for Inspection of a Non-weld Alteration or Repair of a Boiler or Fired Pressure Vessel" - Arizona

Form ADOSH ICA2222 or the "Request For Inspection Of A Non-weld Alteration Or Repair Of A Boiler Or Fired Pressure Vessel" is a form issued by the Industrial Commission of Arizona.

The form was last revised in August 1, 2016 and is available for digital filing. Download an up-to-date Form ADOSH ICA2222 in PDF-format down below or look it up on the Industrial Commission of Arizona Forms website.

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Download Form ADOSH ICA2222 "Request for Inspection of a Non-weld Alteration or Repair of a Boiler or Fired Pressure Vessel" - Arizona

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The Industrial Commission of Arizona
Division of Occupational Safety and Health
BOILER SAFETY SECTION
800 West Washington Street Phoenix AZ 85007-2922
REQUEST FOR INSPECTION OF A NON-WELD ALTERATION OR REPAIR OF A BOILER OR
FIRED PRESSURE VESSEL
An owner, user or licensed contractor must request an Inspection prior to performing an alteration or repair of a boiler or
a fired pressure vessel in the State of Arizona in accordance with R20-5-404.B, and R20-5-406.
OWNER OR USER
PHONE
MAILING ADDRESS
CITY
STATE
ZIP CODE
BOILER/FIRED PV LOCATION
CITY
STATE
ZIP CODE
TENTATIVE START-UP
TENTATIVE ALTERATION/REPAIR DATE
DOES OWNER/USER CARRY BOILER/PRESSURE VESSEL INSURANCE? YES
NO
IF YES, WHO IS THE INSURANCE CARRIER'S NAME (NOT AGENT'S NAME)
PURPOSE OF ALTERATION/REPAIR:
AZ: Arizona issued number
NB: National Board number
Note: above information is found on manufacturer's data plate and/or Manufacturer's Data Report
State Contr. Lic. No.
Name of Firm (Installer)
Complete Mailing Address
City:
State
Zip Code
Telephone:
Fax:
Date:
Contact Person/Title On-site:
Telephone:
Title:
Signature:
Submitter Email Address:
Date:
Submit
=====================================================================================
FOR OFFICE USE ONLY
REQUEST: Acceppted_______________Date_______________
Denied__________________Date_____________
Signature:
Title
____________________________________________
______________________________________
ADOSH ICA 2222-Rev 08.01.16
The Industrial Commission of Arizona
Division of Occupational Safety and Health
BOILER SAFETY SECTION
800 West Washington Street Phoenix AZ 85007-2922
REQUEST FOR INSPECTION OF A NON-WELD ALTERATION OR REPAIR OF A BOILER OR
FIRED PRESSURE VESSEL
An owner, user or licensed contractor must request an Inspection prior to performing an alteration or repair of a boiler or
a fired pressure vessel in the State of Arizona in accordance with R20-5-404.B, and R20-5-406.
OWNER OR USER
PHONE
MAILING ADDRESS
CITY
STATE
ZIP CODE
BOILER/FIRED PV LOCATION
CITY
STATE
ZIP CODE
TENTATIVE START-UP
TENTATIVE ALTERATION/REPAIR DATE
DOES OWNER/USER CARRY BOILER/PRESSURE VESSEL INSURANCE? YES
NO
IF YES, WHO IS THE INSURANCE CARRIER'S NAME (NOT AGENT'S NAME)
PURPOSE OF ALTERATION/REPAIR:
AZ: Arizona issued number
NB: National Board number
Note: above information is found on manufacturer's data plate and/or Manufacturer's Data Report
State Contr. Lic. No.
Name of Firm (Installer)
Complete Mailing Address
City:
State
Zip Code
Telephone:
Fax:
Date:
Contact Person/Title On-site:
Telephone:
Title:
Signature:
Submitter Email Address:
Date:
Submit
=====================================================================================
FOR OFFICE USE ONLY
REQUEST: Acceppted_______________Date_______________
Denied__________________Date_____________
Signature:
Title
____________________________________________
______________________________________
ADOSH ICA 2222-Rev 08.01.16
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