Form Cc0511 – Fill Out and Use This PDF

Minnesota Department of Labor and Industry

Construction Codes and Licensing Division

PO Box 64219

St. Paul, MN 55164-0219

HAS ACTUALLY OPERATED A

Note: Do not use manufacturers horsepower ratings. For Licensing purposes, 10 square feet of heating surface = One Boiler Horsepower, or if H.S. cannot be discerned, 67,000 btu/hr input = One Boiler Horsepower. Reference rule 5225.1000. For high pressure A or B licenses, one year is equal to 2000 hours, reference rule 5225.0550, Subp. 10. Minnesota Residents: may only claim operating experience gained while the applicant had a valid license.

and/or HOT WATER BOILER PLANT

*This affidavit should be filled out and signed by the Chief Engineer of the Plant. If there is not a Chief Engineer at the location the affidavit may be signed by an individual possessing a second class license or higher, or may be signed by the employer.

Pursuant to Minn. Stat. § 326B.082, subd. 11(b)(2), submission of a false or misleading experience affidavit or other document relating to a license application provides cause for a civil penalty of up to $10,000 as well as the suspension or revocation of the license(s) of any person involved in such a submission.

The information provided on this form is used to determine if the applicant meets the license requirements. The requested information is required to process the license application. Failure to provide the requested information may delay the processing of license application or may be grounds for denying your application. Under M.S. § 13.41, the information that is provided on this form, except for the applicant’s name and address, is private data while the application is pending.

Disclosure of this information to others may occur as authorized or required by law, including the Attorney General’s Office, the Department of Revenue, the Department of Human Services, and/or for the purpose of verification and investigation. Once the applicant is licensed, the information becomes public data and will be part of the agency’s permanent records.

This material can be provided in different forms, such as large print, Braille or audiotape, if you call 1-800-342-5354 (DIAL-DLI) or (651) 297-4198/TDD.

CC0511 Boiler Engineer License Affidavit (4/13)

Affidavits must be filled out by your previous employers and/or your current employer, indicating the amount of time served as an operating engineer, as defined in Minnesota Rules, Chapter 5225, or see License Classification handout.

MINNESOTA RESIDENTS MAY ONLY CLAIM OPERATING EXPERIENCE GAINED WHILE THE APPLICANT HAD A VALID LICENSE

Military or Maritime service does not require the completion of an affidavit. You may submit your DD214(s) or documentation from military or maritime service verifying actual operating experience. For additional information regarding military or maritime documented experience, please contact our office at (651) 284-5031.

The original affidavit(s) must be fully completed in ink, notarized and returned to our office with the appropriate fees and application. The applicant should retain a copy for his/her personal records.

There will be no refund of fees paid, so be sure that your affidavit(s) are complete and specific in showing your actual boiler operating experience. No credit can be given for the time that is not verified by your affidavit(s). Affidavit(s) must cover the minimum time requirement for the license applied for.

Applicants who reapply must pay the application fee each time an application is submitted.

Example of an entry on a boiler affidavit in which the applicant would be qualified to take a 1C examination:

NOTES:

1.Do not use manufacturers horsepower ratings. For licensing purposes, 10 square feet of heating surface (H.S.) = One Boiler Horsepower, or if H.S. cannot be discerned, 67,000 btu/hr input = One Boiler Horsepower. Referenced in Minnesota Rule 5225.1000. For electric Boilers 10kw = One Boulder horsepower

2.MINNESOTA RESIDENTS MAY ONLY CLAIM OPERATING EXPERIENCE GAINED WHILE THE APPLICANT HAD A VALID LICENSE.

BEFORE MAILING YOUR AFFIDAVITS, ALONG WITH YOUR APPLICATION AND FEE, PLEASE NOTE THE FOLLOWING: All licenses with the exception of Special Engineer license require submission of both an application and affidavit(s).

APPLICATION:

•All mandatory information is fully completed.

•Proper fee submitted via check or money order payable to Department of Labor and Industry. Please do not send cash.

AFFIDAVITS:

•Notarized properly with a current commission expiration date.

•Fully completed.

•Filled out by the employer, or other person in authority signing for the employer, or person possessing a valid Minnesota Second Class Engineer’s License or higher.

•Required total amount of time shown with specific dates of employment indicated.

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.

Instructions for CC0511 Boiler Engineer License Affidavit (4/13)