Form SH380 "New York State Boiler Repair Certificate of Authorization Application and Quality Control System Review" - New York

What Is Form SH380?

This is a legal form that was released by the New York State Department of Labor - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2016;
  • The latest edition provided by the New York State Department of Labor;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form SH380 by clicking the link below or browse more documents and templates provided by the New York State Department of Labor.

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Download Form SH380 "New York State Boiler Repair Certificate of Authorization Application and Quality Control System Review" - New York

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New York State Department of Labor
Division of Safety and Health - Boiler Safety Bureau
Harriman State Office Campus
Building 12, Room 165
Albany, NY 12240
New York State Boiler Repair Certificate of Authorization Application and
Quality Control System Review
Use this form to apply for a boiler Repair Certificate of Authorization and review of your Quality Control System.
You must make all boiler repairs and alterations according to Industrial Code Rules 4 and 14 provisions.
Mail the completed application to the address above. Be sure to keep a copy for your records.
If you have questions or need more information:
See the Quality Control System Information sheet, SH-381
Visit our web site at: http://labor.ny.gov/workerprotection/safetyhealth/DOSH_BOILER_SAFETY.shtm
Contact the Chief Inspector at the address above or call: (518) 457-2722
Application date: __________________
Location of shop to be reviewed:
⎕ New certificate
Address: ___________________________________
This application is for a (check one):
⎕ Renewal of certificate: Expiration date: _______
___________________________________
___________________________________
⎕ Owner/User shop location only
Your Authorized Insurance Inspection Agency
Type of repair certificate requested (check one):
Information:
⎕ Shop and field locations
Name: _____________________________________
_____________________________________
Company Information:
Address: ___________________________________
Name: _____________________________________
_____________________________________
_____________________________________
Phone:_____________________________________
Address: ___________________________________
Your Authorized Insurance Company Inspection
____________________________________
Agency must notify the Bureau when they have
approved your Quality Control System.
____________________________________
Federal Employer Identification Number
We will then schedule your review. We will notify
you of the date, time and name of the Inspector
(FEIN): _____________________________
who will conduct the review with your Insurance
Company Representative.
Representative’s name: _______________________
Title: ______________________________________
You must send a copy of your approved Quality
Control Manual to the assigned Inspector at least
Phone: ____________________________________
15 days before the review date or your review will
be cancelled.
SH 380 (0316)
New York State Department of Labor
Division of Safety and Health - Boiler Safety Bureau
Harriman State Office Campus
Building 12, Room 165
Albany, NY 12240
New York State Boiler Repair Certificate of Authorization Application and
Quality Control System Review
Use this form to apply for a boiler Repair Certificate of Authorization and review of your Quality Control System.
You must make all boiler repairs and alterations according to Industrial Code Rules 4 and 14 provisions.
Mail the completed application to the address above. Be sure to keep a copy for your records.
If you have questions or need more information:
See the Quality Control System Information sheet, SH-381
Visit our web site at: http://labor.ny.gov/workerprotection/safetyhealth/DOSH_BOILER_SAFETY.shtm
Contact the Chief Inspector at the address above or call: (518) 457-2722
Application date: __________________
Location of shop to be reviewed:
⎕ New certificate
Address: ___________________________________
This application is for a (check one):
⎕ Renewal of certificate: Expiration date: _______
___________________________________
___________________________________
⎕ Owner/User shop location only
Your Authorized Insurance Inspection Agency
Type of repair certificate requested (check one):
Information:
⎕ Shop and field locations
Name: _____________________________________
_____________________________________
Company Information:
Address: ___________________________________
Name: _____________________________________
_____________________________________
_____________________________________
Phone:_____________________________________
Address: ___________________________________
Your Authorized Insurance Company Inspection
____________________________________
Agency must notify the Bureau when they have
approved your Quality Control System.
____________________________________
Federal Employer Identification Number
We will then schedule your review. We will notify
you of the date, time and name of the Inspector
(FEIN): _____________________________
who will conduct the review with your Insurance
Company Representative.
Representative’s name: _______________________
Title: ______________________________________
You must send a copy of your approved Quality
Control Manual to the assigned Inspector at least
Phone: ____________________________________
15 days before the review date or your review will
be cancelled.
SH 380 (0316)