Iowa Division of Labor
Elevator Safety
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-725-5612/515-725-5608
Fax: 515-242-5076
james.borwey@iwd.iowa.gov
www.iowaelevators.gov
Installation/Alteration
Extension Request
$100.00 Extension Fee
Approved Denied
Extended through:
Initials: Date:
Complete the entire form. Submit the completed form, supporting documents and $100.00 check or
money order to the address above.
This request will be denied if more than 12 months have passed since the initial application was received.
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:
(length must be justified) 30 days 60 days
Initial
application date:
Describe in detail the reason for the extension
Signature Date
02.21.2020
600-018
FOR OFFICE USE ONLY
Submit this request during the 10
th
month of permit issuance - IAC 71.5(6)
click to sign
signature
click to edit