Fillable Elevator Safety Mailing address: 1000 East Grand Avenue, (State of Iowa - OCIO)

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Elevator Safety Mailing address: 1000 East Grand Avenue, (State of Iowa - OCIO)

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Iowa Division of Labor
Elevator Safety
Mailing address: 1000 East Grand Avenue, Des Moines, IA 50319-0209
Physical address: 150 Des Moines Street, Des Moines, IA 50309 (FedEx/UPS)
Phone: 515-725-5612/515-725-5608
Fax: 515-242-5076
james.borwey@iwd.iowa.gov
www.iowaelevators.gov
Hazard Correction
Extension Request
Approved Denied
Extended through:
Initials: Date:
Complete the entire form and submit supporting documents, including a copy of the Inspection
Report/Safety Order. This request will be denied if more than 90 days have passed since the safety
order was issued.
Individual Completing Form
Name
Title
Company name
Fax number
Email address
Address
City
State
Zip
Conveyance Information
Building name
Address/location
City
State
Zip
State ID:
Duration of extension request: 30 days 60 days
(length must be justified)
Inspection dates:
Describe in detail the reason for the extension
Copy of inspection report or safety order attached
Signature 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.
09.06.2018
600-013
FOR OFFICE USE ONLY
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Elevator Safety Mailing address: 1000 East Grand Avenue, (State of Iowa - OCIO)

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Completed 20 July 2020

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