Form G45007-1 "Boiler Extension Request Form" - New Hampshire

What Is Form G45007-1?

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

Form Details:

  • Released on January 29, 2020;
  • The latest edition provided by the New Hampshire 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 fillable version of Form G45007-1 by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Labor.

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Download Form G45007-1 "Boiler Extension Request Form" - New Hampshire

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State of New Hampshire
Department of Labor
PO Box 2076
Concord, NH 03302-2076
http://www.nh.gov/labor
Phone: 603-271-2585
Email: B.E.Inspection@dol.nh.gov
Fax: 603-271-2668
Extension Request Form
Boiler Certificate
RSA 157-A:8 & Administrative Rule Lab 1203.03
Please type or print clearly. Form must be complete. Incomplete forms will be returned to the inspector of record.
Date of Request:
Requested End Date of Extension:
Inspection Agency of Record:
State Number(s):
Other # (NB or Oth):
Owner:
Nature of Business:
Insp Type:
Cert. Insp:
Owner Street Address:
Owners City:
State:
Zip:
Object Location – County:
Users Name - Object Location:
Specific Location in Plant:
Users Street Address:
Users City:
State:
Zip:
Boiler(s) or Vessel(s):
Year Built:
Manufacturer:
Maximum Allowed Working Pressure:
Pressure Relief Valve Pressure:
Reason For Request Of Extension:
Proposed Plan To Correct Failure:
Additional Information:
Name, Title, and Contact Information of Person Requesting Extension:
“As the inspector of record, I certify that the length of time requested for this extension will not jeopardize the safety of the general public.”
Name:
NH ID#
Signature:
Date:
I request this form be returned to me by
E-mail :
Mailing Address:
To Be Completed by DOL:
Approve
Deny
Reason for Denial:
Extension Granted until:
Date of review:
by:
G45007-1
1-29-2020
State of New Hampshire
Department of Labor
PO Box 2076
Concord, NH 03302-2076
http://www.nh.gov/labor
Phone: 603-271-2585
Email: B.E.Inspection@dol.nh.gov
Fax: 603-271-2668
Extension Request Form
Boiler Certificate
RSA 157-A:8 & Administrative Rule Lab 1203.03
Please type or print clearly. Form must be complete. Incomplete forms will be returned to the inspector of record.
Date of Request:
Requested End Date of Extension:
Inspection Agency of Record:
State Number(s):
Other # (NB or Oth):
Owner:
Nature of Business:
Insp Type:
Cert. Insp:
Owner Street Address:
Owners City:
State:
Zip:
Object Location – County:
Users Name - Object Location:
Specific Location in Plant:
Users Street Address:
Users City:
State:
Zip:
Boiler(s) or Vessel(s):
Year Built:
Manufacturer:
Maximum Allowed Working Pressure:
Pressure Relief Valve Pressure:
Reason For Request Of Extension:
Proposed Plan To Correct Failure:
Additional Information:
Name, Title, and Contact Information of Person Requesting Extension:
“As the inspector of record, I certify that the length of time requested for this extension will not jeopardize the safety of the general public.”
Name:
NH ID#
Signature:
Date:
I request this form be returned to me by
E-mail :
Mailing Address:
To Be Completed by DOL:
Approve
Deny
Reason for Denial:
Extension Granted until:
Date of review:
by:
G45007-1
1-29-2020