Date Received
Control #
ELEVATOR SUBCODE
Date Issued
TECHNICAL SECTION
Permit #
A. IDENTIFICATION—APPLICANT: COMPLETE ALL APPLICABLE INFORMATION. WHEN CHANGING
CONTRACTORS, NOTIFY THIS OFFICE. CALL UTILITY DIG NO: 1-800-272-1000. C. CERTIFICATION IN LIEU OF OATH
Block Lot
Qualification Code I hereby certify that I am the (agent of) owner of record and am authorized to make
this application.
Work Site Location
Sign here:
Owner in Fee:
Print name here:
Tel.
e-mail
D. TECHNICAL SITE DATA
Address
street municipality zip code
DESCRIPTION OF WORK
Contractor/Installer: Tel.
Address
e-mail
Home Improvement Contractor Registration No. or Exemption Reason
QTY. ITEM
FEE (Office Use Only)
$
Federal Emp. ID No. FAX:
Traction or Winding Drum
Maintenance/Service Contractor 1 to 10 Floors
Address
Over 10 Floors
e-mail
Hydraulic
Tel _____ FAX _____ Roped Hydraulic
B. ELEVATOR CHARACTERISTICS
Escalator/Moving Walk
Building Use Group
Building Registration No.
Dumbwaiter
Manufacturer
Device I.D
.
Stairway Chairlift, Inclined and
Machine Room Location Vertical Wheelchair Lifts and Man Lifts
No. of Stops
No. of Openings
Oil Buffers
Travel (ft.) Speed (f.p.m.)
Counterweight Governor and Safeties
Type of Control Type of Operation
Auxiliary Power Generator
Alterations
Passenger Freight
Other
Capacity (lbs.)
Other
Year of Installation Year of Alteration
Estimated Cost of Elevator Work $
Administrative Surcharge $
JOB SUMMARY (Office Use Only)
State Permit Surcharge Fee
$
TOTAL FEE $
PLAN REVIEW
INSPECTIONS
Dates (Month/Day)
[ ]
No Plans Required
Type: Failure Failure
Approval Initial
[ ] Building Plans and Elevator Specs.
Temporary
Date:
Approved by:
Final
[ ] Elevator Layout Drawings
Date:
Approved by:
Joint Plan Review Required:
SUBCODE APPROVAL for CERTIFICATE
[ ] Bldg. [ ] Elec. [ ] Plumb. [ ] Fire.
[ ] CO [ ] CA
U.C.C. F150 (rev. 11/09)
Applicant: When submitting this form to your Local Construction Code
SUBCODE APPROVAL for PERMIT
Internet version
Enforcement Office, please provide one original plus three photocopies.
Date:
Date:
Approved by:
Approved by:
