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Get Department Of Safety & Professional Services

State of Wisconsin Department of Safety Professional Services Division of Industry Services MECHANICAL REFRIGERATION INSTALLATION REGISTRATION Installing Contractor shall prepare this form in triplicate and distribute as follows 1 - Send to Wisconsin Dept of Safety Professional Services Madison Wisconsin 53707-7302 OR Email to mailto DSPSSBBoilerRegistration Wisconsin.gov REFRIGERATION SYSTEMS TYPE Self Air Cond. User Email Address Phone number City State Zip County Date Installation Completed Installer Signature Contractor Telephone CONNECTIONS Welded Brazed Soldered WI Registration Tag No. Site Address Recr. User Email Address Phone number City State Zip County Date Installation Completed Installer Signature Contractor Telephone CONNECTIONS Welded Brazed Soldered WI Registration Tag No. Site Address Recr. Other Site Name Mfg. or Storage HP KVA Pounds in System Serial No. DISTRIBUTION PIPING Steel Copper Indirect REQUIRED CAPACITY Tons Refrigerant User or Owner Name Direct USE 2 - Send to Owner who shall POST IT IN A CONSPICUOUS PLACE. 3 - Retain for file. Other Site Name Mfg. or Storage HP KVA Pounds in System Serial No. DISTRIBUTION PIPING Steel Copper Indirect REQUIRED CAPACITY Tons Refrigerant User or Owner Name Direct USE 2 - Send to Owner who shall POST IT IN A CONSPICUOUS PLACE. 3 - Retain for file. Complete appropriate portion Threaded HVAC Contractor Required Exp. Number Expiration Date Zip Code e-mail Date Registered Personal information you provide may be used for secondary purposes Privacy Law s.

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