Fillable INSTALLATION -FOR OFFICE USE ONLY 150 Des Moines (Office of the Chief Information Officer)

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INSTALLATION -FOR OFFICE USE ONLY 150 Des Moines (Office of the Chief Information Officer)

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-FOR OFFICE USE ONLY
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
elevators@iwd.iowa.gov
www.iowaelevators.gov
APPLICATION FOR
INSTALLATION
OR ALTERATION PERMIT
FOR OFFICE USE ONLY
INSTRUCTIONS
Please type or print clearly. No installation or alteration shall begin until a permit has been issued. Submit a separate form for each
conveyance. Submit a complete application package in order to prevent delays. Alterations require drawings and specifications
for all planned changes. New installations require 2 copies of the project details set forth in 875 IAC 71.5. Plans must be submitted
on 11”x17” paper. A single electronic plan submittal shall be made with sufficient resolution to not lose detail when enlarged.
A building code analysis document must also be submitted.
Date Received:
Approved Denied
Date: By:
State ID #:
Comments:
Fee Schedule:
Traction Elevator Installation: $1,000.00 Hydraulic Elevator Installation: $750.00 Elevator Alteration: $500
Escalator Installation: $1,000.00 Escalator Skirt Brush Alteration: $500.00 Other Escalator Alteration: $1,000.00
Wheelchair Lift Installation: $500.00 Wheelchair Lift Alteration: $500.00 Dumbwaiter Alteration: $500.00
Dumbwaiter Installation: $500.00 Print Revision: $100.00 Permit Extension: $100.00
Application Type: New Installation or Complete Replacement of Existing Equipment
Alteration Skirt Brush Alteration A17.3 Alteration ($250.00)
Owner’s name
Owner’s address
City
State
Phone
Building name
Conveyance address
City
County
Zip
Conveyance contractor
Contact
Email
Phone
Address
City
State
Zip
General contractor
Contact
Email
Phone
Address
City
State
Zip
Owner ID (example: North Car #1)
Installation code year
Date conveyance contract signed
Alteration code year
General
# of
landings
# of front
openings
# of rear
openings
Rated load
lbs
Rated speed
. ftm
MRL
Yes No
Contractor job number
Type of equipment: Passenger Freight A Freight B Freight C1
Freight C2 Freight C3 Sidewalk Limited use (LULA)
Special purpose Moving walk Dumbwaiter Material Lift
Escalator
. Vertical platform lift Inclined platform lift Restricted (alteration only)
Type of drive unit:
Cable ball and socket Chain (Electric) Chained hydraulic Rack and pinion Roped hydraulic
Direct hydro Screw
Traction Winding drum Other:
600-001
02.21.2020
Page 1 of 2
State ID#:
Machine
Machine type:
Single wrap Double wrap
Geared traction Gearless traction
Machine location:
Basement Overhead Remote
Pit Side
Brake type:
.
Disc. Drum
Car weight
.
lbs
Counter weight:
. lbs
Rope construction:
X
Rope material:
Top of hoistway
Steel
.
Other:
Type rope fastenings:
.
Babbit. Wedge clamp
Belt: Yes No
If yes, Belt model #:
FT-1 rated:
. Yes No
Hydraulic control valve manufacturer
Hydraulic control model #
Drive sheave or drum size:
inches
Deflection sheave size:
inches
Compensation chain or other
# of chains (VPL)
Size of chains
Hoistway, Machine Room and Pit
Type of hoistway doors
Type of car doors
# of ropes
Size of ropes
# of chains
Size of chains
Manufacturer
Manufacturer model name and serial #
IBC code
edition year
Fire rating of building: .None. 1 hr. 2 hr
Type of operation: Automatic. Manual. Continuous pressure
Type of emergency Phone
communication in car: Intercom
Type of hoistway construction: Concrete. Sheetrock.
. Glass. Other:
Type of machine room construction: . Concrete
.
Sheetrock. Other:
Machine room vent:
. Yes. No
Sump pump:
. Yes. No
Pit ladder:
. Yes. No
Hoistway vent:
. Yes. No
Buffer type: . Poly . Spring . Oil . Bumper
Buffer stroke
inches:
Guide rail type: . Tee. Formed. Angle. Omega. U-channel. Pipe .
. Other:
Guide rail sizes: Car Counterweight
Building NFPA design? 13 13R N/A
Is elevator part of Yes
an accessible route? No
Fire Fighters’ Service and Fire Safety
Fire fighter’ service:
None Phase I Phase I & II
Location of remote fire
recall switches
Main
evacuation level
Alternate
evacuation level
Machine room
sprinklers: . Yes. No
Top of hoistway
sprinklers: . Yes. No
Pit
Sprinklers: . Yes. No
Pit fire detection means:
. Smoke. Heat. N/A
Safety Device
Safety device type: .
. A. B. C. Other:
Speed governor type: .
. Centrifugal. Fly-Ball. Friction. Other:
Governor manufacturer
Governor model #
Safety manufacturer
Safety
model number
Car safety switch:
. Yes. No
Slack rope switch:
. Yes. No
Counterweight safeties:
. Yes. No
Compensating ropes:
. Yes. No
Size of
governor rope:
Type of
governor rope
Ascending car overspeed and unintended
car movement protection: . Yes. No
Electrical
Horsepower
Power from more than 1 source:
. Yes. No
Volts (main)
Phase
Volts (battery if applicable)
Emergency lowering only: . Yes. No
Emergency stand-by power: . Yes. No
I certify that the information on this form and attachments (if any) is true and accurate to the best of my knowledge.
Printed name of applicant
Title
Phone number
Email address
Signature
Date
Application for Installation or Alteration Permit Continued State ID #:
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INSTALLATION -FOR OFFICE USE ONLY 150 Des Moines (Office of the Chief Information Officer)

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Completed 20 July 2020

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