Absa Form Ab 41A – Fill Out and Use This PDF

AB-41a, Page 1 of 2

				2006-08
			Guide for Completing Form AB-41
				Statutory Declaration form
						Registration of Fittings
		STATUTORY DECLARATION				In this space, show facsimile
						of manufacturer s logo or
		Registration of Fittings				trademark as it will appear on
See Guidance Notes on page 2.						the fitting.
I,	(2)	,
				(1)
	(3)

(company title, e.g. vice president, plant manager, chief engineer) (must be in a position of authority)

of	(4)
			(name of manufacturer)
located at	(5)
				(plant address)
do solemnly declare that the fittings listed hereunder, which are subject to the Safety Codes Act
(check one)
comply with the requirements of			(6)		which specifies the dimensions,
			(title of recognized North American Standard)
materials of construction, pressure/temperature ratings and identification marking of the fittings, or
are not covered by the provisions of a recognized North American standard and are therefore manufactured to
comply with	(7)			as supported by the attached data which identifies the dimensions,

materials of construction, pressure/temperature ratings and the basis for such ratings, and the marking of the fittings for identification.

I further declare that the manufacture of these fittings is controlled by a quality control program which has been verified by the

following authority,	(8)	as being suitable for the manufacture of these fittings to the
stated standard. The fittings covered by this declaration, for which I seek registration, are				(9)
In support of this application, the following information, calculations and/or test data are attached:
	(10)

DECLARED before me at

(11)

in the

of

this

day of

, _________

(Month)

(Year)

(print)

(12)

(Signature of Applicant)

(sign)

(13)

(A Commissioner for Oaths)

For Office Use Only

To the best of my knowledge and belief, the application meets the requirements of the Safety Codes Act and CSA Standard B51, Clause 4.2, and is accepted for registration in Category

Registration Number:

		(For the Administrator/Chief Inspector of Alberta)
Date Registered:		Expiry Date:

The information you provide is necessary only for the administration of the programs as required by the Alberta Safety Codes Act and Regulations in the Boiler Discipline.

AB-41a, Page 2 of 2

Guidance Notes

for Completing the Statutory Declaration Form (AB-41)

(1)In this space indicate what permanent marking will be on the fittings to identify the Manufacturer.

(2)The person completing the form must be in a position to commit the Manufacturer to a legally binding contract.

(3)Company title: e.g. Vice President, Plant Manager, Chief Engineer or

(4)The name of the Manufacturer, not a sales agent, distributor or outside division which does not exercise control over the manufacturing process.

(5)The address is the physical address of the manufacturing facility to which the quality control program applies.

(6)recognized North American Standard implies the ASME/ANSI B16 series of fittings and some MSS fittings. Give the number of the standard, e.g. ASME/ANSI B16.5-1996. Codes such as ASME Section VIII are not standards that establish the required data for fittings and must not be what is inserted in (6).

(Choose only (6) or (7) whichever is appropriate, but not both), and click on the box to the left of that space.

(7)not covered by the provisions of a recognised North American Standard applies to all configurations of fittings not covered by (6). Such other fittings might be to a proprietary standard or to some published standard that, for example, includes dimensions but does not include the grades of materials to be used.

(Choose only (6) or (7) whichever is appropriate, but not both), and click on the box to the left of that space.

(8)Verification of the quality control program is to have been conducted by a credible independent third- party agency acceptable to ABSA. Typical acceptable agencies would include any boiler and pressure vessel regulatory authority in a Canadian province; an ASME Authorized Inspection Agency, such as the Hartford Steam Boiler Inspection & Insurance Co.; Lloyds Industrial Register; Det Norske Veritas; the Quality Management Institute and like agencies. There is to be a copy of a document from that agency attesting to the fact that a suitable quality control program exists and that it is being implemented by the Manufacturer.

(9)	Describe the fittings briefly, e.g. Ball Valves or B/W Elbows or	Only one category of fittings can be
	represented on a Statutory Declaration.

(10)List the supporting documents relating to the fitting, by reference number if possible. These may include drawings, catalogues, bulletins or brochures which list therein the manufacturers rating, dimensions, material specifications and such other information as may be required by the Design Surveyor.

Details shall include the ASTM specification numbers of the materials of construction, dimensions, the name of the standard to which the fittings are manufactured (proprietary fittings shall be identified as such) and the pressure and temperature ratings assigned to the fittings;

One set of design calculations or other appropriate basis for establishing the pressure/temperature ratings. Proof tests must have been witnessed by a National Board-commissioned Inspector;

(11)Example: DECLARED before me at Edmonton in the Province of Alberta

this 1st day of November, 2000.

(12)The signature of applicant must be of the same person who is completing the Statutory Declaration Form. (ref. (2) above)

(13)The Statutory Declaration Form is required to be countersigned by a Commissioner for Oaths or Notary Public.