GEORGIA DEPARTMENT OF LABOR

1700 CENTURY CIRCLE

ATLANTA, GEORGIA 30345
MICHAEL L. THURMOND EARL EVERETT
COMMISSIONER DIRECTOR, SAFETY ENGINEERING

State Special No. Fee $500.00

APPLICATION FOR A STATE SPECIAL BOILER OR PRESSURE VESSEL

1. Name and Address of Company (Owner/User) where Boiler or Pressure Vessel will be installed

2. Name and address of Company requesting the Special

3. Contact Person's Name Telephone No.

4. BOILER UNFIRED PRESSURE VESSEL

5. Manufactured by Year

A. Type of Object Serial No.

B. Boiler Capacity - Heating Surface or BTU/HR or LB. STM/HR

C. Size of Unfired Pressure Vessel

D. Design Operating Pressure Operating Pressure Requested

All Design Documents must accompany this Application such as; Drawings, Calculations, Material Specification on all Material,
and any other information that may be applicable.

Please Remit To:

GEORGIA DEPARTMENT OF LABOR
Safety Engineering
Signature of Applicant Date
1700 Century Circle
Must be CERTIFIED by a Registered Professional Engineer Atlanta, Georgia 30345
experienced in the design of boilers and Pressure Vessels. APPROVAL

Signature of Engineer Date Signature of Authority

State Registration No. Title Date

Telephone Number: (404) 679-0687

An Equal Opportunity Employer/Program DOL-4240 (R-3/01)