Form Dic4302 - Report Of Welded Repair Alteration

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Ohio Department of Commerce
John R. Kasich
Governor
Division of Industrial Compliance
Bureau of Operations and Maintenance, Boilers
6606 Tussing Road
P.O. Box 4009
Jacqueline T. Williams
l
Director
Reynoldsburg, OH 43068-9009
(614) 644-2223 FAX (614) 644-2428
REPORT OF WELDED REPAIR________ ALTERATION________
PLEASE PRINT OR TYPE
Work done by
State ID No
Company______________________________Address___________________________________
____________
Owner
Na tional Bd No
Name ________________________________Address____________________________________ ____________
Location of
Manufacture
Installation____________________________Address____________________________________
____________
Type (CI,FB,HT,SM,ETC)
Manufacture
Other
Year
_____________________
Serial No_________________
________________ Built ____________
Description of Work
(use back to make sketch if necessary)
______________________________________________________________________________________________
Remarks: Attached are Manufacture’s Partial Data Reports properly identified and signed by Commissioned
Inspectors for the following items of this report (name of part item mfg’s name and identifying stamp)
______________________________________________________________________________________________
CERTIFICATE OF COMPLIANCE
We certify that the statements in this report are correct and that all (Design) _________________________ material,
construction, and workmanship on this (repair/alteration) ___________________ Conform to the Ohio State Code.
Date _________________ (repair organization) ___________________________ (Rep.) ______________________
Certificate of Authorization No. _______________ To use the __________________ Symbol expires_____________
CERTIFICATE OF INSPECTION
I, the undersigned, an Ohio Commissioned Inspector, employed by ______________________________________ of
__________________________________ have inspected the work described in this Data Report on ______________
and state to the best of my knowledge and belief, this work has been done in accordance with the Ohio Boiler
Inspection Code.
By signing this report, neither the inspector nor his employee makes any warranty, expressed or implied concerning
the work described in this Data Report. Furthermore, neither the inspector nor his employees shall be liable in any
manner for any personal injury or property damage or a loss of any kind arising from or connected with this
inspection, except such liability as may be provided in a policy of insurance which the inspector’s insurance company
may issue upon said request.
Date________________ Inspector______________________________ Commission No.______________________
FINANCIAL INSTITUTIONS • INDUSTRIAL COMPLIANCE • LIQUOR CONTROL • REAL ESTATE AND PROFESSIONAL LICENSING • SECURITIES • STATE FIRE MARSHAL • UNCLAIMED FUNDS
“An Equal Opportunity Employer and Service Provider”
DIC4302 (Rev 05.03.05)

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