State inspector’s printed name
State inspector’s signature
Fold on the dotted line and display top portion in elevator
Elevator Safety
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-725-5612/515-725-5608
Fax: 515-242-5076
elevators@iwd.iowa.gov
www.iowaelevators.gov
Temporary Construction Permit Application
Approved Denied
Issue date:
ID #: Exp. Date:
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities.
For deaf and hard of hearing, use Relay 711.
Application and permit fees must be paid before a permit will be issued.
Initial inspection fee - $200.00 Renewal inspection fee - $100.00
The safety test was performed under the rated load.
Landing entrances are guarded, locked and unlocked from the hoistway side only.
Landing call buttons are not operated unless the hoistway door-locking devices are installed and operative.
A notice is posted at each entrance stating the equipment has not been finally accepted.
I certify the elevator complies with the requirements found in Iowa Administrative Code Section 72.23(89A) and with ASME A17.1,
Section 5.10. The elevator will be used for construction materials and construction personnel only.
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signature
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