The Doh 347 form is a document used in the State of Ohio for the purposes of filing workers' compensation claims. The form can be filed by an employee who has been injured on the job, or by a representative on behalf of an employee. The Doh 347 form must be completed and filed within one year of the injury date. Filing a workers' compensation claim can be complex, so it is important to seek legal assistance if you have any questions about completing the Doh 347 form.
| Question | Answer |
|---|---|
| Form Name | Doh 347 Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | doh 347 form, form doh 347, doh347, application backflow form |
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Public Water Supply Protection
Application for Approval of Backflow Prevention Devices
PRINT OR TYPE ALL ENTRIES EXCEPT SIGNATURES |
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Lot # |
FOR DEPARTMENT USE ONLY |
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Please completed items 1 through 12a + Block and Lot Numbers |
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Log No. |
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1. |
Name of Facility |
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2. |
City, Village, Town |
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3. |
County |
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4. |
Location of Facility |
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4a. Phone Numbers |
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5. |
Contact Person |
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5. |
Approx. Location of Device(s) |
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Mfg. Model # |
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Size of Device(s) |
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# of Fire Services
# of Domestic Services
# of Combined Services
Total # of Services
Total # of Buildings
7. Name of Owner |
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Title |
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Phone Number |
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8. |
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Nature of works |
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Initial Device Installation |
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Replace Existing Device |
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Full Mailing Address |
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8a. |
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Address |
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New Service |
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Existing Service |
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8b. |
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New Building |
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Owner's Signature |
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Date |
_____/_____/_____ |
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Existing Building |
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Major Renovations |
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9. Name of Design Engineer or Architect |
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10. |
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NYS License # |
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Address |
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Other |
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City |
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10a. |
Telephone Number(s) |
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Signature |
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Original Ink signature and seal required on all copies |
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Date |
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_____/_____/_____ |
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11. Water System Pressure (psi) at Point of Connection |
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12. |
Estimate Installation Cost |
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12a. |
Estimate Design Cost |
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Max ________ |
Avg ________ Min ________ |
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13. Degree of Hazard |
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List of processes or reasons that lead to degree of hazard checked: |
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Hazardous |
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Aesthetically Objectionable |
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14. Public water supply name |
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Name of supplier's designate representative |
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Mailing Address |
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Title |
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___________________________________________________ |
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_____________________________________________________ |
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____________________________________________________________________ |
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Signature _________________________ |
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Telephone No. ( |
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Note: All applicants must be accompanied by plans, specifications and an engineer's report describing the project in detail. The project must first be submitted to the water supplier, who will forward it to the local public health engineer. This form must be prepared in quadruplicate with four copies of all plans, specifications and descriptive literature.