Boiler or Pressure Vessel Installation App

Application for Permission to Install a Boiler or Pressure Vessel (Lethal Service)

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(Office Use Only The Inspector may be contacted at the following telephone number

1) * Permit Action Applying For:

New Installation

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Reinstallation

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Second-Hand Installation

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_______________________________________________________________________________________________________________________________________________2) Category of Vessel to be Installed:

(example: water heater)

3) Location Address:

Send Certificate To?

User Location: Owner Address: *Billing Address:

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Is the business currently covered by an Insurance Inspector?

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When applying for multiple installations at one location. *An application is required for each boiler installed*

*Have all additional state/local installation permits been obtained?

A guideline for completion of this document is located on Page 3

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4) Manufacturer's Data Report: Reference 0800-03-03-.04 (1) (b) (c)Attached Information Supplied at Time of Inspection

Page 2 of 2

5) Size & Clearance: Reference 0800-03-03-.08 (4) (a)

Information Supplied at Time of InspectionAttached Seperately

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Measurement from Point/Obstruction to Vessel (Signify in Feet and/or Inches )

A DCB

Overhead Clearance

Vessel Dimensions: Diameter

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Plant Location, Exits & Ventilation: Ref. 0800-03-03-.08 (5) (6) (a) & (b) Location in plant.

Room Ventilation Louver Size (sq/ft)

Combustion Air Louver Size (sq/ft)

Variance Review Approval: Approved by ________

Date _______________

7) Controls and Safety Devices

Information Supplied at Time of InspectionAttached Seperately

a) Boiler Capacity asure: Lb/hr Kw/hr

b) Boiler Horsepower

f) Remote Emergency Shutdown Installed: Yes (Required on Boilers Over 400,000 Btu/hr Only, Hot Water Supply Boilers Exempt )

No N/A

c) Fuel Type: Gas- Natural Gas- LP Oil Electric Wood Waste Coal Other

d) Firing Method: Forced Draft Atmospheric Element Auger Stoker Other

Boiler Heating Surface (sq/ft)

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g) Safety Valves: NumberTotal Capacity

Size Set Pressure Capacity8) *Installer Information

State

Zip

City

Address

Name

Contact

Fax Number

Phone Number

9) *Preferred Mode of Return : (select one)

Email To:Email Address

Fax To:Fax Number

OwnerMail To: Installer

Number of Exits from the Boiler Room?

6)

Contractor

Not Applicable ( waterheater less than 200,000 Btu/hr)

Boiler/Mechanical Room Dimensions:

X sq. ftor

ofBoiler Number

RLB-0936 Rev. 06-17

GUIDE FOR COMPLETING APPLICATION FOR PERMIT TO INSTALL

Note: All information signified with an "*" is required and must be completed

1) The action that the installer is requesting. The installation is a New Installation, Reinstallation, or Second-Hand Installation (A Mfr. Data Report is required at time of application for Second-Hand boilers not previouslyregistered in TN). At least one of the three actions must be selected. The installer should then indicate anyapplicable underlying action that supplements the installation action. If the installer is planning to installmultiple boilers at the same location, the installer is required to complete and submit individualapplications for each boiler installed. The installer shall also indicate a number to reference each individualboiler requesting to be installed.

2) This is the category of boiler (or lethal service pressure vessel) that is intended to be installed. The installershall then indicate from the underlying selections which use type of boiler will be installed. If a lethalservice pressure vessel is being installed, the installer shall indicate the medium that will be stored in thevessel and the maximum allowable working pressure (MAWP) the vessel is rated to operate at. The installeris responsible for obtaining all required additional state/ local permits priorto installation!

3) a) Indicate if the location where the boiler (vessel) is to be installed currently is inspected by a Tennessee commissioned insurance inspector, and provide the name of the insurance agency if so. If the installer isunaware if the location is insured or not, the installer may indicate this by checking the "Unk" boxprovided (unknown).b) The installer shall indicate whom the certificate of inspection should be sent to after the inspection hasbeen completed. If left blank, the certificate will automatically be sent to the Billing Address.c) The User Location address shall be completed entirely, including a contact name and telephone number.Failure to provide this information will result in the denial of the application. The Owner and Billing Addressshall either be completed entirely or indicated as being the same as user, or same as owner for thebilling address.

4) Where applicable, the Manufacturer's Data Report shall either be attached and submitted with theapplication or supplied to the inspector at time of inspection, and indicated accordingly. A Mfr. Data Reportis required at time of application for Second-Hand boilers not previously registered in TN.

5) The installer shall attach a separate document, supply the information at time of inspection, or completethe information spaces pro vided.

6) a) The specific location (room) where the boiler or vessel is to be located in the plant.b) The installer shall indicate how many means of exit are located from the room where the boileris located.c) Indicate the square-feet (sq./ ft.) of ventilation for both room venting and combustion.

7) The installer shall either attach a separate document, supply the informationat time of inspection, or complete the information spaces provided.

8) The installer shall provide the complete Installer Information, including any required Contractor LicenseNumber. Failure to provide this information will result in the denial of the permit. Check with the localauthority where the boiler is to be installed for any additional local licensing or permitting requirements.

9) Once the application has gone through the approval process, the installer shall indicate how he wouldprefer to receive the response. The installer shall choose one of the modes provided. After receiving theresponse, the installer shall post the approved permit at the location where the boiler is to be installed andhave available to the inspector at time of inspection.

The installer shall be aware that the installation requirements of Rules 0800-3-3 will be enforced at time of application and inspection, and an approved permit only a preliminary approval of the requested installation. Failure to adhere to the rules may result in the denial of the final installation at time of inspection.

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