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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