ELEVATOR CERTIFICATE COMBINED FEE WORKSHEET
Building Name:
ELBI #:
Address:
Contact Name:
Phone Number:
Address:
DECAL NUMBER
Filing Fee
($20)
Waiver Fee
($50 per
violation)
Delay Fee
($50 per
violation)
Late Fee
(see note for
calculation)
Total Due
6.
7.
8.
17.
18.
19.
CHECK NUMBER
TOTAL DUE
Use this worksheet to submit one check to pay the fees for up to 20 units. List each decal number and then mark each fee
that pertains to that piece of equipment. Add all of the fees due and submit one check in the amount along with all of the
appropriate paperwork for each Certificate of Compliance.
Make checks payable to the Texas Department of Licensing and Regulation.
*A late fee is due after 60 days from the date of inspection, at a rate of $10 per every 30 days over the 60th day.
TDLR Form ELE016 rev August 2021