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The CC0511 form, officially known as the Boiler Engineer License Affidavit, serves a crucial role in Minnesota’s construction and engineering licensing process. Administered by the Minnesota Department of Labor and Industry, this form is used to verify the operating experience of individuals applying for Chief, First Class, and Second Class Boiler Engineer licenses. Applicants must provide a detailed account of their time operating steam and hot water boiler plants, as well as any experience with steam engines or turbines. The affidavit must be completed by a qualified supervisor or employer, ensuring it reflects accurate work history and the specific hours operated, with particular guidelines detailing how horsepower is calculated for licensing purposes. It is vital for applicants to fully understand the requirements, as incomplete submissions could lead to processing delays or even denial of their license. Once the information is verified and the application is approved, details transform from private to public data, reinforcing the importance of accuracy in this document. With specific attention to details like notarization and mandatory information, the CC0511 form is essential for anyone seeking to advance their career as a boiler engineer in Minnesota.

Cc0511 Example

Minnesota Department of Labor and Industry

Construction Codes and Licensing Division

PO Box 64219

St. Paul, MN 55164-0219

Phone:

(651) 284-5031

 

Boiler Engineer License Affidavit

 

(Chief, First Class, and Second Class Licenses)

E-mail:

dli.license@state.mn.us

 

 

 

 

 

Website: www.dli.mn.gov

 

 

 

 

 

I,

 

 

 

 

, upon oath duly administered, declare that to my personal knowledge,

(*chief engineer, second class engineer higher or employer)

 

 

 

 

 

the applicant:

 

 

of:

 

 

 

 

 

 

 

 

 

 

(city and state)

operator’s license number

 

 

 

 

(of Applicant, if applicable),

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.

STEAM BOILER PLANT

Total Horsepower

Maximum Working Pressure (psi)

From

Month Day Year

To

Month Day Year

and/or HOT WATER BOILER PLANT

BTU Input/KW/Horsepower Pressure

Temperature

From

Month Day Year

To

Month Day Year

And (if application) STEAM ENGINES OR STEAM TURBINES

Total Horsepower

 

From

 

To

 

Month

Day Year

Month

Day Year

 

 

 

 

 

NOTE: For High Pressure Boiler Operation enter Total Operating Hours

*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.

*Name of Chief Engineer or Employer

Title or Grade of License and Number

Work Phone Number (include Area Code)

 

 

 

(Employer) Name and Address

 

 

City

State

Zip Code

Subscribed and sworn to before me this

 

day of

, 20

 

 

 

 

by

 

 

 

 

 

 

 

 

 

(*Signature of chief engineer, second class engineer or higher or employer)

 

 

 

 

 

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 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)

Minnesota Department of Labor and Industry

Construction Codes and Licensing Division

Licensing and Certification Services

PO Box 64219

St. Paul, MN 55164-0219

Phone: (651) 284-5031

E-mail: dli.license@state.mn.us

Website: www.dli.mn.gov

Instructions for Completing the

Boiler Affidavit

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:

STEAM BOILER PLANT

Total Horsepower

150

Maximum Working Pressure (psi)

15

From

Month Day Year

06

01

1997

To

Month Day Year

06

01

2000

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)

Form Characteristics

Fact Name Description
Purpose The CC0511 form is used to provide an affidavit for applicants seeking a Boiler Engineer License in Minnesota.
Governing Law This form is governed by Minn. Stat. § 326B.082, which outlines licensing requirements and penalties for false submissions.
Authority The Minnesota Department of Labor and Industry oversees the licensing process related to this affidavit.
Notarization Requirement Completion of the affidavit must include notarization to ensure validity, highlighting the need for official verification.
Operating Experience Applicants can only claim experience gained with a valid license in Minnesota, ensuring accountability in the licensing process.
False Submissions Penalty Submitting misleading information may result in a penalty of up to $10,000, or even suspension or revocation of the license.
Contact Information Questions regarding the affidavit can be directed to the Department of Labor and Industry via phone or email.
Alternate Formats The form and guidance can be provided in alternative formats, such as Braille or large print, upon request.

Guidelines on Utilizing Cc0511

Once you gather the necessary information, proceed to complete the CC0511 form accurately to ensure a smooth application process. Check to make sure all required sections are filled out and that you're providing the necessary experience details as per the guidelines.

  1. Obtain the form: Download or print the CC0511 form from the Minnesota Department of Labor and Industry website.
  2. Fill in your name: At the top of the form, write your name or the name of the Chief Engineer or employer (who is signing the affidavit).
  3. Detail the applicant's information: Include the name of the applicant and their operator’s license number (if applicable) in the designated spaces.
  4. Specify the steam boiler plant details: List the total horsepower and maximum working pressure (psi) in the provided fields. Provide the dates of operation.
  5. Fill in hot water boiler plant information: Record the BTU input/KW/Horsepower and pressure temperature. Again, provide the relevant date range.
  6. Include steam engines or turbines: If applicable, enter total horsepower for steam engines or turbines along with the operational dates.
  7. Include total operating hours: For high-pressure boiler operation, note down the total operating hours.
  8. Provide employer details: Fill in the name, title, and contact information of the employer or person signing the affidavit.
  9. Affix the notarization: Sign the form in the designated area. The affidavit must be notarized by a licensed notary public.
  10. Make copies: Before submission, make copies of the completed affidavit for your records.
  11. Submit the form: Send the original notarized affidavit along with your application and any fees to the Minnesota Department of Labor and Industry.

Completing these steps diligently will help you submit a thorough application, minimizing the risk of delays or rejections. Always keep a copy of your submissions for your personal records.

What You Should Know About This Form

What is the purpose of the CC0511 form?

The CC0511 form, known as the Boiler Engineer License Affidavit, is used to verify the experience of an applicant for various boiler engineer licenses in Minnesota. It must be filled out by the applicant's employers to confirm their operating experience in a boiler setting.

Who can complete the CC0511 form?

The form should be completed and signed by the Chief Engineer of the plant where the applicant was employed. If there is no Chief Engineer, a person with a valid Second Class License or higher, or the employer themselves, can sign the affidavit.

What information is required on the form?

Key information includes the applicant's name, the details of the steam or hot water boiler plant where they worked, total horsepower, maximum working pressure, and specific dates of employment. The form needs to be detailed to provide an accurate account of the applicant’s operating experience.

How does the affidavit relate to licensing requirements?

The affidavit serves to demonstrate that the applicant meets the experience requirements set by the state for the specific boiler engineer license being sought. Failure to provide adequate proof of experience can result in delays or denial of the license application.

What happens if false information is provided in the affidavit?

Providing false or misleading information in the CC0511 form can lead to serious consequences. This includes civil penalties of up to $10,000, as well as potential suspension or revocation of licenses for individuals involved in the submission.

Can military or maritime experience be used for this affidavit?

Yes, military or maritime service experience can be counted toward licensing requirements. However, in such cases, you need to submit documents like DD214s instead of filling out the CC0511 form.

Is there a fee associated with submitting the form?

Yes, there is a fee that must be submitted along with your application and completed affidavit. This fee needs to be paid via a check or money order made out to the Department of Labor and Industry. Cash is not accepted.

What should I do if I need assistance with the form?

If you need help or have questions about completing the CC0511 form, you can contact the Minnesota Department of Labor and Industry at (651) 284-5031. They can provide guidance and answer any specific inquiries you may have.

How should I submit the completed CC0511 form?

The completed form should be notarized, then mailed to the Minnesota Department of Labor and Industry with your application and fee. It is important to keep a copy for your personal records, as no refunds are given for fees paid.

When does the information on the form become public?

While your application is pending, most information on the CC0511 form is considered private data. Once you receive your license, the data becomes public and will be part of the agency's permanent records.

Common mistakes

Completing the CC0511 form, which is crucial for obtaining a Boiler Engineer License in Minnesota, can be fraught with pitfalls. Many applicants unwittingly make common errors that can delay their application or even lead to its rejection. Recognizing and avoiding these mistakes can save time and frustration.

One frequent mistake is not listing the correct organization or company name where the applicant gained their operating experience. The form requires precise identification of the employer; any ambiguity could lead to confusion regarding employment verification. It's essential to check for spelling accuracy and ensure that all names are officially recognized.

Another error arises when applicants fail to provide specific details about their operating experience. The CC0511 form explicitly requests the total horsepower for steam boiler plants and the BTU input for hot water boiler plants. Omitting this vital information or providing vague estimates can hinder the evaluation process.

Many individuals also neglect the notarization requirement. The affidavit must be signed and adequately notarized by an authorized individual. Failure to comply with this requirement can invalidate the submission. It is advisable to review the signature sections closely and confirm that a current notary public has completed their part accurately.

Timeframe discrepancies represent another common issue. Applicants often miscalculate the employment duration needed to meet licensing requirements, entering incorrect start and end dates. The form requests precise month, day, and year for each position held, and providing these details accurately is crucial. Missing or incorrect dates can lead to a denial based on insufficient operating experience.

In addition, applicants sometimes overlook the requirement to include a personal declaration statement. The form begins with an oath that must be duly administered, affirming knowledge about the applicant's experience. Not completing this section correctly can create legal complications and impede the application process.

Lastly, many applicants forget or miscalculate the fees associated with submitting the application and affidavits. The CC0511 form requires that all mandatory fees be submitted in one of the accepted forms of payment, such as check or money order. Ensuring that the correct amount is submitted along with all accompanying documents is vital to prevent delays due to payment issues.

Avoiding these seven pitfalls when completing the CC0511 form can significantly enhance the chances of a smooth application process, ensuring that applicants stay on the path to obtaining their Boiler Engineer License without unnecessary hiccups.

Documents used along the form

The CC0511 form, or the Boiler Engineer License Affidavit, plays a crucial role in the licensing process for boiler engineers in Minnesota. This affidavit must be completed accurately by an eligible individual who can verify the operating experience of the license applicant. Several other documents and forms complement the CC0511 form, each serving a distinct purpose in the application process.

  • Application Form: This form collects essential personal and professional information from the applicant. It must be filled out entirely and is required along with the CC0511 to process the licensing request. Missing information may result in delays.
  • Affidavit of Operating Experience: Often required from previous employers or current employers, this affidavit verifies the applicant's operational experience in specific boiler plants. It must include detailed employment dates and the type of equipment operated.
  • DD214 Form: For applicants with military or maritime experience, the DD214 form serves as documentation of service. This form can substitute for the traditional affidavits required under typical circumstances.
  • License Classification Handout: This informational handout outlines the different types of boiler engineer licenses available in Minnesota. It aids applicants in understanding the requirements necessary for each classification and their corresponding operational experiences.

Including these forms along with the CC0511 ensures that applicants meet all necessary regulations and requirements set forth by the Minnesota Department of Labor and Industry. Proper completion and submission of each document can facilitate a smoother licensing process for prospective boiler engineers.

Similar forms

  • Affidavit of Experience: This document serves a similar purpose by providing a detailed account of an individual's work experience in a specific field. It typically requires signatures from employers or qualified individuals, similar to the CC0511 form.

  • Licensure Application Form: Like the CC0511, this form is essential for obtaining a license. It collects personal and professional information to assess eligibility, ensuring all necessary data is included for processing.

  • Employer Verification Letter: This document verifies employment and experience, confirming that a person has performed specific tasks under a qualified supervision, paralleling the CC0511's need for verification from employers.

  • Notary Acknowledgment Form: Similar to the CC0511, this form requires notarization to affirm that the provided information is truthful and accurate, serving as an official validation of the signed affidavit.

Dos and Don'ts

When filling out the CC0511 form for the Boiler Engineer License Affidavit in Minnesota, it's essential to follow specific guidelines to ensure a smooth application process. Here are seven key dos and don’ts to keep in mind:

  • Do gather all necessary information before completing the form, including employment dates and operating experience details.
  • Do ensure that the affidavit is signed by the appropriate authority, such as the Chief Engineer or an individual with a valid license.
  • Do use ink to fill out the form, as this is required for notarization.
  • Do include accurate total horsepower and working pressure figures according to licensing guidelines.
  • Don’t use manufacturers’ horsepower ratings; instead, follow the defined standards for boiler horsepower.
  • Don’t forget to notarize the affidavit before submitting it along with your application and payment.
  • Don’t leave any mandatory fields blank, as this may delay the processing of your application.

By adhering to these dos and don’ts, you can increase the chances of a successful application. Thorough preparation and attention to detail can make the process smoother.

Misconceptions

Here are some common misconceptions about the CC0511 form related to boiler engineer licensing:

  • It's only for Minnesota residents. While the form has specific rules for Minnesota residents, individuals from other states may also use the form if meeting the necessary requirements.
  • Anyone can fill out the affidavit. This form must be completed by a Chief Engineer, a licensed individual, or the employer. It cannot be filled out by just anyone.
  • Brands of boilers called for horsepower ratings. The affidavit specifically requires operating experience in square feet of heating surface or BTUs, not manufacturer ratings.
  • Military service experience is not valid. Military or maritime service experiences are accepted and verified through DD214 documentation.
  • Once submitted, the information remains private indefinitely. Initially, the information is private, but once the application is approved, it becomes public data.
  • The affidavit does not need to be notarized. Notarization is a requirement before submission to validate the information provided.
  • There is a refund policy for application fees. No refunds are available after fees are submitted, regardless of the outcome.
  • You can claim any hours worked. Only hours worked while holding a valid license count towards the experience required.
  • Any signature will suffice on the affidavit. The form must be signed by an authorized individual, i.e., Chief Engineer or employer, to be valid.
  • The application processing time is always quick. Submission accuracy and completeness are crucial; otherwise, it may lead to delays in processing.

Key takeaways

When filling out and using the CC0511 form, consider the following key takeaways:

  • Accuracy is crucial: Ensure all entries regarding operating experience are correct and match your actual time served. Errors may lead to delays or denial of your application.
  • Notarization requirement: The affidavit must be notarized. Unauthorized signatures or lack of notarization can jeopardize the validity of the form.
  • Operating experience restrictions: Minnesota residents may only include operating experience gained while holding a valid license. Double-check that your records comply with this stipulation.
  • Types of experience accepted: If you have military or maritime experience, you can substitute that documentation instead of filling out an affidavit.
  • Submit complete documentation: Include all required affidavits, fees, and a properly completed application to avoid processing delays. Incomplete submissions will not be processed.

Pay careful attention to these points to ensure smooth processing of your Boiler Engineer License application.