Fillable Elevator Safety the planned installation. Include a check (Office of the Chief Information Officer)

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Elevator Safety the planned installation. Include a check (Office of the Chief Information Officer)

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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
Application to Install
Construction Personnel Hoist
Instructions
To prevent processing delays submit a completed application at least 60 days before
the planned installation. Include a check or money order payable to the Iowa
Division of Labor for the amount calculated below. New installations require 2
copies of the project details set forth in 875 IAC 71.5. Plans must be submitted on
11”x17” paper or a single electronic plan submittal shall be made with sufficient
resolution to not lose detail when enlarged.
Fees
Base fee: The base fee for a construction personnel hoist (CPH) is $500.00. Jump
Inspection Fee: You must submit with this application a $150.00 inspection fee for
each time you plan to jump (or increase) the number of floors served.
Inspections
A CPH must be inspected prior to first use, at least once each quarter, and prior to
the first use after additional floors are added. The Division of Labor must be notified
at least 7 days before a planned jump inspection.
Date Received:
Check #:
Date Approved: By:
Permit # CPH:
Comments:
FOR OFFICE USE ONLY
General Contractor
Name
Phone number
Building name
City
State
Zip
Contact for Job Site
Name
Job title
Phone number
Job Site
Address
City
State
Zip
Manufacturer
Rated
speed
Capacity
Removal date
# of landings
in initial phase
# of jumps
expected
Final # of
landings
Applicant’s name Signature Title Date
02.21.2020
600-006
#of Jumps
X
Subtotal:
+ Base Fee
Total Fee:
$150.00
$ 0.00
$500.00
$ 500.00
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Elevator Safety the planned installation. Include a check (Office of the Chief Information Officer)

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Completed 13 August 2020

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