Fillable Elevator Safety 150 Des Moines Street Des Moines, (Office of the Chief Information Officer)

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Elevator Safety 150 Des Moines Street Des Moines, (Office of the Chief Information Officer)

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Data Plate Information
Rated
capacity: lbs
Rated
speed: fpm
Governor overspeed
switch:
Governor
JAW trip: fpm
Front door (2000 or later) (Code zone)
closing speed: sec
Rear door (2000 or later) (Code zone)
closing speed: sec
Controller
manufacturer:
Category 1
Is Test Satisfactory?
8.6.4.19.1 Oil buffers
P F N/A
8.6.4.19.2 Safeties type (no load) A B C
P F N/A
8.6.4.19.3 Governors
P F N/A
8.6.4.19.4 Slack-rope devices and stop motion on winding drum machines
P F N/A
8.6.4.19.5 Normal and final terminal stopping devices
P F N/A
8.6.4.19.6 Firefighters’ emergency operation
P F N/A
8.6.4.19.7 Standby or emergency power operation (no load)
P F N/A
8.6.4.19.8 Power operation of door system: Door closing speed (Code zone): Front sec; Rear sec;
Door closing force: Front lbf; Rear lbf
P F N/A
8.6.4.19.9 Broken rope, tape or chain switch
P F N/A
8.6.4.19.10 Functional safety of SIL rated devices
P F N/A
8.6.4.19.11 Ascending car overspeed protection and unintended car motion devices
P F N/A
8.6.4.19.12 Traction loss detection means
P F N/A
8.6.4.19.13 Broken-suspension member and residual strength detection means
P F N/A
8.6.4.19.14 Occupant evacuation operation
P F N/A
8.6.4.19.15 Emergency communications
P F N/A
8.6.4.19.16 Means to restrict hoistway or car door opening
P F N/A
Miscellaneous concerns – list on page 2
Y N
Category 5 – Must complete Category 1 with this section
8.6.4.20.1 Car: Gov jaw trip: fpm; Gov overspeed switch: fpm; Gov Safety slide distance: in;
Safety release carrier pull force: lbf; Gov pull through force: lbf
Counterweight: Gov jaw trip: fpm; Gov overspeed switch: fpm; Safety slide distance: in;
Safety release carrier pull force: lbf; Gov pull through force: lbf
P F N/A
8.6.4.20.2 Governors
P F N/A
8.6.4.20.3 Oil buffers
P F N/A
8.6.4.20.4 Driving machine brakes (apply a seal and tag)
P F N/A
8.6.4.20.6 Emergency terminal stopping and speed-limiting devices
P F N/A
8.6.4.20.7 Power opening of doors
P F N/A
8.6.4.20.8 Leveling zone and leveling speed
P F N/A
8.6.4.20.9 Inner landing zone
P F N/A
8.6.4.20.10 Braking system, traction and traction limits
P F N/A
8.6.4.20.11 Emergency brake
P F N/A
The tests were performed in compliance with ASME 17.1, A117.1, and Iowa Code 89A and in accordance with the code in effect at time of the original
installation and/or any applicable alteration(s). Complete page 2 for each failed item.
(check all that apply)
Type: Passenger Freight LULA Restricted SPPE MRL
# of front
landings:
# of rear
landings:
Total # of
landings:
Periodic Traction Elevator Test
Iowa Division of Labor
Elevator Safety
150 Des Moines Street
Des Moines, IA 50309
Phone: 515-725-5612/515-725-5608
Fax: 515-242-5076
elevators@iwd.iowa.gov
www.iowaelevators.gov
State ID
Check one:
. Annual 5 Year
Last category 1
test date:
Last category 5
test date:
Building name
Owner name
Address
Company Performing Test Company Address, City, State, Zip Date
Individual Performing Test Signature Witness (if required) QEI#
Page 1 of 2
click to sign
signature
click to edit
Unsatisfactory Test Component
REF #
(Page 1)
Part
Violative
Condition
Suggested
Remedy
Corrected
During
Test
Comments
Part
Inside Car
01 Emergency stop switch
02 Alarm system
03 Car phone
04 Car enclosure
05 Side emergency exit
06 Car door/gate
07 Car door/gate contact
08 Door reopening device
09 Car sill to hatch sill
10 Car floor
11 Car door gibs
12 Car button station
13 Car lighting
14 Emergency lighting
15 Car mirror
16 Certificate frame
Hoistway
17 Hoistway doors
18 Hoistway door gibs
19 Hoistway door
reinforcements
20 Hoistway door safety
retainer
21 Vision panel
22 Interlocks
23 Parking device
24 Hall button station
25 Indicators
26 Car door restrictor
Top of Car
27 Top emergency exit
cover
28 Governor release carrier
29 Door hangers &
connectors
30 Door operator
31 Normal limits
32 Final limits
33 Guide shoes/roller
guides
34 Counterweight
35 Hoistway
36 Electrical wiring
37 Pipes and ducts
38 Overhead & deflector
sheave
39 Traveling cable &
junction
40 Car top
Machine Room
41 Machine room
42 Machine room door
43 Controller—selector
44 Reverse phase relay
45 Traction sheave
46 Governor
47 Governor switch
48 Drum
49 Pump unit
50 Drum machine limit SW
51 Generator
52 Slack rope switch
53 Hoist cables
54 Governor ropes
55 Car counterweight rope
56 Drum counterweight
rope
57 Hoist machine
58 Hoist motor
59 Worm/gear/bearings
60 Machine brake
61 Lighting machine space
62 Machine disconnect SW
63 Commutator
64 Motor brushes
65 Unintended car
movement
66 Emergency brake/rope
gripper
67 Communication
68 Maintenance log
69 Code data plate
Pit
70 Pit
71 Pit light
72 Pit stop switch
73 Car guide-rails &
brackets
74 Cwt guide-rails &
brackets
75 Buffers
76 Car safety & tail rope
77 Underside platform
78 Tension weight
79 Comp/chains/ropes/
switch
80 Counterweight runby
81 Counterweight runby
signage
82 Plunger gripper
Miscellaneous
83 Entire device
84 Miscellaneous
Violative Conditions
A Altered
B Insufficient
C Padlocked
D Unsecured
E Rubbing
F Lost motion
G Improper fuses
H Worn
I Damaged
J Misaligned
K Rusted
L Defective
M Missing
N By-Passed
O Dirty
P No means of access
Q Unguarded
R Illegal
S Not fire retardant
T Unlabeled
U Device not tagged
V Not level
W Unlocked
X Inoperative
Y Oil leak
Z Water leak
AA Carbon buildup
BB Expired tag
Suggested Remedy
01 Adjust
02 Clean
03 Install guards
04 Patch
05 Perform test
06 Properly secure
07 Provide
08 Regroove
09 Remove
10 Repair
11 Replace
12 Reshackle
13 Seal
14 Shorten
15 Tag device
16 Provide means of
access
17 Reinspection required
02.21.2020
600-004
Page 2 of 2
State ID #:
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Elevator Safety 150 Des Moines Street Des Moines, (Office of the Chief Information Officer)

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Completed 20 July 2020

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