Guide for Completing Form AB-41 - ABSA

AB-41a, Page 1 of 22006-08Guide for Completing Form AB-41Statutory Declaration formRegistration of FittingsSee Guidance Notes on page 2.I, (2) ,(3)STATUTORY DECLARATIONRegistration of Fittings(company title, e.g. vice president, plant manager, chief engineer) (must be in a position of authority)In this space, show facsimileof manufacturer s logo ortrademark as it will appear onthe fitting.(1)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, orare not covered by the provisions of a recognized North American standard and are therefore manufactured tocomply 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 fittingsfor identification.I further declare that the manufacture of these fittings is controlled by a quality control program which has been verified by thefollowing authority, (8) as being suitable for the manufacture of these fittings to thestated 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 ofthis day of , _________(Month)(Year)(print) (12)(Signature of Applicant)(sign) (13)(A Commissioner for Oaths)For Office Use OnlyTo 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 CategoryRegistration Number:Date Registered:(For the Administrator/Chief Inspector of Alberta)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 2Guidance Notesfor 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 bindingcontract.(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 notexercise control over the manufacturing process.(5) The address is the physical address of the manufacturing facility to which the quality control programapplies.(6) recognized North American Standard implies the ASME/ANSI B16 series of fittings and some MSSfittings. Give the number of the standard, e.g. ASME/ANSI B16.5-1996. Codes such as ASMESection VIII are not standards that establish the required data for fittings and must not be what isinserted in (6).(Choose only (6) or (7) whichever is appropriate, but not both), and click on the box to the left ofthat space.(7) not covered by the provisions of a recognised North American Standard applies to all configurationsof fittings not covered by (6). Such other fittings might be to a proprietary standard or to somepublished standard that, for example, includes dimensions but does not include the grades ofmaterials to be used.(Choose only (6) or (7) whichever is appropriate, but not both), and click on the box to the left ofthat space.(8) Verification of the quality control program is to have been conducted by a credible independent thirdpartyagency acceptable to ABSA. Typical acceptable agencies would include any boiler andpressure 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 NorskeVeritas; the Quality Management Institute and like agencies. There is to be a copy of a documentfrom that agency attesting to the fact that a suitable quality control program exists and that it is beingimplemented by the Manufacturer.(9) Describe the fittings briefly, e.g. Ball Valves or B/W Elbows or Only one category of fittings can berepresented on a Statutory Declaration.(10) List the supporting documents relating to the fitting, by reference number if possible. These mayinclude drawings, catalogues, bulletins or brochures which list therein the manufacturer s rating,dimensions, material specifications and such other information as may be required by the DesignSurveyor.Details shall include the ASTM specification numbers of the materials of construction, dimensions, thename 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/temperatureratings. Proof tests must have been witnessed by a National Board-commissioned Inspector;(11) Example: DECLARED before me at Edmonton in the Province of Albertathis 1 st day of November, 2000.(12) The signature of applicant must be of the same person who is completing the Statutory DeclarationForm. (ref. (2) above)(13) The Statutory Declaration Form is required to be countersigned by a Commissioner for Oaths orNotary Public.