Boiler Intent to Install - Department of Labor & …
DEPARTMENT OF LABOR & INDUSTRY BUREAU OF OCCUPATIONAL & INDUSTRIAL SAFETY
File #
Loc #
PA Serial #
Date
BOILER INTENT TO INSTALL
This form must be submitted for each unit to be installed
EXPEDITE REVIEW. ADDITIONAL FEE SUBMITTED. ACT 24 EXEMPTION
Owner Information
Name Mailing address
Location Information
City Phone
Name Physical address
County Fax
State Email
ZIP code
Applicant Information
City Municipality name
Name Mailing address
County Type:
State PA
Borough
City
ZIP code Township
City Phone
County Fax
State Email
ZIP code
By signing this form, I acknowledge my understanding that approval of this installation is contingent upon compliance with all of the requirements (including any relating to financial responsibility) of Act 85, Boiler and Unfired Pressure Vessel Law (35 P.S. ?? 1331.1-1331-21) and the Boiler and Unfired Pressure Vessel Regulations (34 Pa. Code ?? 3a.1-3a. 171) and that a site inspection and final approval issued by the Department of Labor & Industry is required prior to use of this installation.
I further acknowledge that if any part of the proposed installation is not in compliance with the applicable regulations, I must submit a request for variance (Form LIIB-303) with this intent prior to installation and await a decision of the Industrial Board regarding my request.
Installation Type Second Hand Information
Boiler Information
Cast Iron Installation Report
FOR L&I USE ONLY
Applicant name (Printed)
Signature of applicant
Date
New
Replacement
Second hand
Former owner name Former location City PA Standard/Special #
State ZIP code National Board #
Boiler manufacturer's name
Year constructed
Boiler manufactured to ASME code
Yes
No
If yes, manufacturer's data report must be provided at time of inspection. (not required for Cast Iron or Cast Aluminum)
If no, documentation complying with 35 P.S. ? 1331.7(b) of the Boiler and Unfired Pressure Vessel Law must be provided.
Boiler was factory assembled
Yes
Maximum allowable working pressure
Hydrostatic test pressure
psi
No psi
Check #:
Amount: $
Bates #:
LIBI-302 REV 08-21 (Page 1)
Filing Requirements
FEE SCHEDULE: For an up-to-date listing of fees, please see the Fee Schedule listed on our website (dli.Individuals/Labor-Management-Relations/bois) or contact our office for a copy of the Fee Schedule by email BOILERS@, by telephone at 717-787-3806 option 3 or by fax at 717-705-7262.
Submit additional documentation and payment by check or money order payable to Commonwealth of Pennsylvania along with this application to:
PA Department of Labor and Industry BOIS ? Boiler Division 651 Boas Street, Room 1606 Harrisburg, PA 17121
LIBI-302 REV 08-21 (Page 2)
Bureau of Occupational & Industrial Safety | Boiler Division 651 Boas Street, Room 1614 | Harrisburg, PA 17121 | 717.787.3806 | F 717.705.7262 | dli.
Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program
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