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Building Codes Division (BCD)

STATE OF OREGON

BOILER MINOR REPAIR PERMIT LOG

Applicant's Business Name
Phone	Fax
Email

EQUIPMENT INFORMATION

Owner's Name
Phone
Address of Vessel Location
City		State:	Zip
Commercial	Residential	Boiler	Pressure Vessel
Description of Vessel
NB/State Number

MINOR REPAIR INFORMATION

Minor Repair Permit Number
Date Work Completed
Check all that apply
Low Water Cut Off	Pressure Relief Valve	Safety Valve	Safety Switch
Rupture Disc	Flame Safeguard	Low Pressure or Temperature Limit	Fuel Train Component
Flame Detector	High Pressure or Temperature Limit	Heat Exchanger Element	Burner Component or Related Operating Control
Detailed description of work performed

If the work was performed by a boiler business contractor, list the names and Oregon license numbers below all Class 1 through Class 5 mechanics who performed the work on this minor repair permit.

Boiler Business License Number
CCB Number
Name	License Number
Name	License Number
Name	License Number
Name	License Number
Name	License Number

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Oregon.gov

Website Links

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