Sample Statutory Declaration and Guide

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Boiler & Pressure Vessel Safety
Statutory Declaration for Registration of Fittings
(a) I,
(see Note 1)
Design Qualification
2 (Position eg, president, plant manager, chief engineer) 3 (name of company)
of located at
4 (plant address)
do solemnly declare that the fittings listed here under comply with all the: requirements of the ANSI/ASME codes which they are required; OR are not covered by the provisions of the ANSI/ASME codes, and are therefore constructed to comply with code or standard, and are designed to the best current engineering practice, as shown by the supporting calculations and test data. (b) Quality Control of Manufacture
6 5 (detail specific code)
as to their dimensions, materials, identification & service for
I further declare the manufacture of these fittings is controlled by a quality control program which complies with the requirements of
7 (detail specific code)
, and has been verified by the following authority or Authorized Inspection agency.
8 9 (list all fittings and models on separate sheet if necessary)
The fittings covered by this declaration, for which I seek registration, are In support of the application, the following information, calculations and /or test data are attached:
Declare before me at In the
11 Commissioner for Oaths Signature of Declarer
(For Official Use Only)
The application is accepted for registration in Category in accordance with CSA Standard B51.
This registration must be revalidated after ten (10) years from the date of acceptance. Registered Number CRN For the Chief Inspector Date:
Notes: 1. This form shall be completed and signed by the President or highest official in the manufacturing plant where the fitting is produced. 2. One completed original of the Statutory Declaration form together with one copy of catalogues, drawings or bulletins illustrating above fittings shall be submitted. 3. All fittings are required to be registered in the Name of the Manufacturer.
The instructions for the statutory declarations are identified by bracketed numbers corresponding to the numbers on the sample declaration. 1. Show the logo or trade mark, which will be on the fittings to identify the manufacturer. 2. Name and position of the person completing the declaration. This person must be in a position of authority, who can commit the manufacturer to a legally binding contract. 3. Name of the fitting manufacturer. The form must not be completed by a sales agent, distributor or outside division which does not exercise control over the manufacturing process. 4. The address must be the physical location of the manufacturing facility where the certified quality control program applies. If there is more than one manufacturing location, a separate declaration is required for each location. Complete 5 or 6 but not both. 5. List the recognized North American standard, which the fitting conforms to. A recognized North American standard is one of the standards listed in ASME Section VIII Div. 1 UG-44 or ASME/ANSI B31 series Pressure Piping Codes Standard Piping Components. 6. List standards, other than recognized North American standards, which the fitting conforms to. Such other standards may be proprietary standards or published standards, which as a minimum, must have requirements for materials, dimensions, pressure/temperature ratings, markings and testing. The declaration shall be supported by a copy of the standard and if necessary, design calculations or proof test results verified by an authorized inspection authority. 7. Standard to which the manufacturers quality control program has been certified. The minimum standard is CSA B51 Annex F. Other acceptable standards are ISO 9001 or 9002. 8. Authorized inspection authority which has certified the manufacturer=s quality control program. Acceptable authorities are Provincial boiler regulatory authority, ASME Authorized Inspection Agency or an agency, which issues ISO 9000 certifications. The declaration must be supported by written documentation from the inspection authority verifying that the manufacturer=s quality control program is satisfactory. 9. List the category and fitting which is to be registered. Where a series of fittings are to be registered collectively in the same category, a complete list of all fittings by make, model and size range shall be provided. A separate sheet may be used if necessary. Category A B C D E F G H Type of fitting Pipe fittings, including couplings, tees, elbows, Y=s unions, nipples, pipe caps or reducers Flanges Valves Expansion joints, flexible connections, and hose assemblies Strainers, filters, separators, steam traps Measuring devices, including pressure gauges, level gauges, sight glasses, levels, pressure transmitters Certified capacity-rated pressure relief devices acceptable as primary overpressure protection on boilers, pressure vessels and pressure piping, and fusible plugs Pressure retaining components that do not fall into one of the above categories
Note: Category “H” may include a series of components (including piping components) joined together to form a single fitting, provided that the inside diameter of any component does not exceed 152 mm (6 in and the total volume of the fitting does not exceed 42.5 L. (1.5 cu. Ft.). 10. List the supporting documents including drawing numbers, catalogue numbers, calculation sheets, bulletins and proof test results. 11. The declaration must be countersigned by a Commissioner of Oaths or Notary Public.