www.MyFloridaLicense.com/dbpr/elevator-safety
Division of Hotels and Restaurants
Bureau of Elevator Safety
2601 Blair Stone Road, Tallahassee, FL 32399-1013
Phone: 850.487.1395 • Fax: 850.922.6208 • Email: dhr.elevators@myfloridalicense.com
PETITION FOR VARIANCE FROM RULE
NOTE: The Bureau of Elevator Safety provides this form for assistance only. This form is not required for submitting a variance
request, but its proper completion will facilitate processing of your variance request. All requirements set forth in Chapter 120, Florida
Statutes (FS), apply to any variance petition.
Type of Variance Requested: Routine (Completed within 90 days) Emergency (Completed within 30 days)
Variance Duration: Permanent Temporary: if temporary, date you will be in compliance
Petitioner or Legal Representative Name:
Title:
Mailing Address:
Building Name:
Building Address:
License Number(s):
PETITION FOR VARIANCE FROM RULE
Consult your registered elevator company or certified elevator inspector with questions about the specific rule(s) to cite.
61C-5.001, FAC, AND
Code:
ASME A17.1,
(edition)
A17.3, 1996
A18.1,
(edition) Other
Code:
ASME A17.1,
(edition) A17.3, 1996 A18.1,
(edition) Other
I request a variance from the above stated rule(s) adopted under Section 399.02, Florida Statutes.
I cannot meet the requirements of the rule(s) because:
I intend to meet the intent of the rule and underlying statute by:
It would be a substantial hardship for me to meet the minimum requirements of the rule because:
This request is being made on an emergency basis because (if applicable):
If you are not the owner or owner’s legal representative, please attach a letter from the owner authorizing you to act on
their behalf and stating that they agree to be held to any provisos required by any order granting a variance.
Attach additional pages if necessary to provide all pertinent information.
