Minnesota Department of Labor and Industry Financial Services/Code 443 Lafayette Road North St.

Paul, MN 55155

HIGH PRESSURE PIPING LICENSE APPLICATION, EXAMINATION AND AFFIDAVIT INSTRUCTIONS
License Examination Requirements Please PRINT IN INK or TYPE your responses. Applications will be denied for illegible or unreadable applications. The Minnesota pipefitter examination has two parts: 1) documented experience, and 2) a written test. Only applications who pass the documented experience part of the examination may take the written test. Applicants who fail the documented experience part of the examination may not take the written test. Application Instructions Basic applicant information: ALL information in this section is mandatory in order to process the application. • • • • • • Applicant’s last name, first name and middle initial. Applicant‘s mailing address (street or post office box) city, state and zip code. Applicant’s social security number Area code and telephone number of Applicant. Area code and Fax number of Applicant, if you have one. Applicant’s date of birth (month, day, year). License Information Instructions If you are applying for a Journeyman license check the box and list your Pipefitter Apprentice number and Pipefitter Trainee Registration number. If you are applying for a Contractors license check the box and list your Journeyman pipefitters license number, if applicable. If you were a Registered Apprentice check the appropriate box. If yes, fill in the years and months as an Apprentice, and the years and months experience with high pressure piping systems. If you were a Registered Trainee check the appropriate box. If yes, fill in the years and months as a Trainee, and the years and months experience with high pressure piping systems. If you were a Journeyman Pipefitter check the appropriate box. If yes, fill in the years and months as a Journeyman, and the years and months experience with high pressure piping systems. Applicant signature and date are required. Name and address of the Registered Apprenticeship program you completed. You must submit a copy of your apprenticeship completion certificate or your apprenticeship indenturement card. List Employer name, address and dates employed. Proof of High Pressure Piping Experience In order to pass the experience part of the examination, applicants must submit written proof of the required years of experience in the installation and/or construction of high pressure piping as a registered pipefitter trainee, registered apprentice, or journeyman pipefitter as prescribed in Minnesota Rules, Chapter 5230, Steamfitter Rules and Codes for Power Piping Systems. The written proof of high pressure piping experience is submitted on affidavits. The affidavits must be filled out by your current employer and/or your previous employers and indicate the amount of time served at the pipefitting trade, as defined in Minnesota Rules, Chapter 5230. The affidavit should be signed by a Minnesota licensed pipefitting contractor that you worked for and include that person’s license number. For experience acquired in other states or jurisdictions, the affidavit should be signed by the appropriate contractor and include any state or jurisdiction license information. Affidavits must cover the minimum time requirements: 4 years for journeyman; 5 years for contractor. No credit is given for time that is not certified by your affidavits.
CAIS HPP-11.WP (7/05) over

Required Information It is essential to provide the specific information regarding high pressure piping work and the dates the work was done. Definition: High pressure piping in Minnesota means any system of piping hot water or other medium used for heating that exceeds 30 P.S.I. gauge and 250 degrees F, or any system of high pressure steam or ammonia piping. The application and affidavit experience must be consistent with this definition. Additional information regarding experience may be presented on the reverse side of the affidavit or on a separate sheet of paper. Examples of entries on affidavits include the following: Applicant helped install 125 psi steam piping at (Project) from (Date) to (Date) Installation of Ammonia refrigeration piping at (Project) from (Date) to (Date)

Project XZY Alcohol Plant

Type of Work Performed by Applicant Helped install 125 psi steam piping

Dates of Employment
From: To:

8-98

5-99

It is recommended that you obtain a code book (Minnesota Rules, Chapter 5230, High Pressure Piping and Code for Power Piping Systems) before you make application for licensing. It sets forth the licensing requirements and may be used as a study guide. A copy may be obtained from the Minnesota State Bookstore, 660 Olive Street, St. Paul, MN 55155. Metro: 651-297-3000. MN Tool Free: 1-800-657-3757. TTY Metro: 651-282-5077. TTY MN Toll Free: 1-800-657-3706 Application Fees $120 $270 - Journeyman pipefitter individual competency examination and license fee. - Contracting pipefitter individual competency examination and license fee.

Applications fees are not refunded. It is important that your affidavits are complete and specific in showing your actual high pressure work experience. Affidavits must be fully completed, notarized, and returned to our office with the appropriate fee and application form. Applications must be received fifteen (15) days prior to examination. BEFORE MAILING YOUR APPLICATION ALONG WITH YOUR FEE, PLEASE NOT THE FOLLOWING: All licenses require submission of both application and affidavit(s). Application: • • • Affidavits: • • • Notarized properly with a current commission expiration date. Fully completed. Required total amount of time shown with specific dates of employment indicated. All mandatory information is fully completed. Proper fee submitted via check or money order payable to Department of Labor and Industry. Do not send cash. Applications must be received 15 calendar days prior to exam.

This material can be provided in different forms, such as large print, Braille or audiotape, if you call (651) 284-5080 or (651) 297-4198/TTY.

Minnesota Department of Labor and Industry Financial Services/Code APPLICATION FOR 443 Lafayette Road North St. Paul, MN 55155 Please PRINT IN INK or TYPE your responses. Unreadable or illegible applications will be denied. Please submit completed application, affidavit, if required, and appropriate fee to the above address.

Reset

PIPEFITTER’S LICENSE
Items with * are required to process your application.

LICENSE NUMBER (If applicable)

SOCIAL SECURITY NUMBER*

LAST NAME *

FIRST NAME *

MIDDLE INITIAL

ADDRESS *

CITY

STATE

ZIP CODE *

AREA CODE AND PHONE NUMBER

AREA CODE AND FAX NUMBER

DATE OF BIRTH *

EXAMINATION INFORMATION* If yes, you do not need to complete RETEST the remainder of this application YES Were you a . . . Registered Apprentice Registered Trainee Journeyman Pipefitter yrs yrs yrs

Journeyman $120 Contractor $270 Applying for: Pipefitter Apprentice Number Pipefitter Trainee Registration Number Years experience with high pressure piping systems mos mos mos yrs yrs yrs DATE * mos mos mos

Years as

I VERIFY THAT ALL INFORMATION IS CORRECT* SIGNATURE OF APPLICATION X Name of Registered Apprenticeship Program you completed Address of Registered Apprenticeship Program you completed
Please submit a copy of your apprenticeship certification of your apprenticeship indenturement card.

Employer

Employer Address

Phone Number
From:

Dates Employed
To:

From:

To:

From:

To:

From:

To:

From:

To:

From:

To:

The information you provide on this application will be used to determine if you meet the license requirements. Before a license is issued to you, M.S. § 270.72, subd. 4, requires you to provide your social security number. The other information is required to process your application. Failure to provide the requested information may delay the processing of your application or may be grounds for denying your application. Under M.S. § 13.41, the information that you provide on this application, except for your 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 you are licensed, the information (except for your social security number) 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 (651) 284-5080 or (651) 297-4198/TTY.
CAIS HPP-06.WP (3/07)

Office Use Only
REASON(S) DENIED: WRC = WRONG SIGNATURE

Approve

Deny

Inspectors Initials

ILL = ILLEGIBLE OR UNREADABLE NOS = NO SIGNATURE ON APPLICATION CIP = COMPLETE IN PENCIL ANN = AFFIDAVIT NOT NOTARIZED NOR = NOT ORIGINAL AFFIDAVIT (copies of faxes not accepted) OTH = OTHER

NOA = NO APPLICATION SUBMITTED NOF = NO FEE SUBMITTED ANS = AFFIDAVIT FORM NOT SUBMITTED ICT = INSUFFICIENT CREDITED TIME IDA = INVALID DATES ON AFFIDAVIT

Office Use Only

Application Number

Date Paid

Amount Paid

Check Number

Money Order Number

Interagency Payment

Purchase Order Number (state agencies only)

Minnesota Department of Labor and Industry Financial Services/Code 443 Lafayette Road North St. Paul, MN 55155 Please PRINT IN INK or TYPE your responses.

HIGH PRESSURE PIPING AFFIDAVIT
Please submit completed affidavit along with application to the above address.

APPLICANT LAST NAME

FIRST NAME

MIDDLE INITIAL

ADDRESS

AREA/PHONE NO.

CITY

STATE

ZIP CODE

NAME OF COMPANY COMPANY ADDRESS

BUSINESS LICENSE NUMBER AREA/PHONE NO.

CITY

STATE

ZIP CODE

NAME OF CONTRACTING LICENSE HOLDER (if applicable)

LICENSE NUMBER (if applicable)

Application applying for: Journeyman Contractor How long has the applicant been continuously employed by you on high pressure piping as defined in Chapter 5230 yrs mos Describe the applicant’s experience in the practical installation of High Pressure Piping, as defined in 5230.0250 of the Minnesota High Pressure Piping code. List specific high pressure piping projects, work performed by the applicant and dates of continuous employment. Project Type of Work Performed by Applicant Dates of Employment
From: To:

From:

To:

From:

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Continue on back

Has the applicant been employed by you as an apprentice pipefitter?

Yes

No

Subscribed and sworn to before me this _____ day of _______________________, 20 ___

by ______________________________________________________________________ (Name of Affiant) Signed ___________________________________________________________________ (Notary) _______________________________ (Stamp)

The information provided on this form is used to determine if the applicant meets the license requirements. The requested information is required to process your 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 you provide 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 (651) 284-5080 or (651) 297-4198/TTY.
CAIS HPP-07.WP (8/04)

Project

Type of Work Performed by Applicant

Dates of Employment
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CODE BOOK ORDER FORM
PREPAYMENT REQUIRED Please send me the following publications: Boiler and Power Boat Rules, $10.00 each (includes M.S. 183.375-183.62) High Pressure Piping Rules and Code for Power Piping Systems, $11.00 each (3-66) (includes M.S. 326.46 – 326.52) (3-19)

$

$ Sub-Total $

(up to $15.00 remit $3.00; $15.04 - $25.00 remit $5.00; $25.01 - $50.00 remit $7.00; $50.01 - $100.00 remit $10.00; over $100 call for rates)

Shipping/Handling $

New Sub-Total $ 6.5% MN Sales Tax (7% for St. Paul Residents) $

Total $ Send to: Name Company Street Address City State Zip Code

Check enclosed payable to: State of Minnesota Charge to: MasterCard / Visa / American Express / Discover Card Number Expiration Date Authorized Signature

Return to: Minnesota Bookstore 660 Olive Street St Paul, MN 55155 Phone No: 651-297-3000 1-800-657-3757

CAIS 23.WP (8/06)