Fillable Illinois Office of the State Fire Marshal APPLICATION FOR CERTIFICATE OF OPERATION - ANNUAL

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Illinois Office of the State Fire Marshal APPLICATION FOR CERTIFICATE OF OPERATION - ANNUAL

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Illinois Office of the State Fire Marshal
Division of Elevator Safety
James R. Thompson Center
100 West Randolph Street, Suite 4-600 Chicago, IL 60601
Phone: 312-814-3435
APPLICATION FOR CERTIFICATE OF
OPERATION - ANNUAL
This application form is strictly for the certificate of operation for each elevator, escalator, platform lift, power-driven stairway
and stairway chairlift (collectively hereinafter referred to as “conveyance”) at your location. The Owner must complete this
application for new and existing conveyance(s). The state will issue a Certificate of Operation only for conveyance(s) located
in a municipality that has not signed an Elevator Safety Program Agreement with the state. Please check with your municipality
before submitting this application.
All application forms must be submitted to the Office of the State Fire Marshal, Elevator Safety Division, James R.
Thompson Center, 100 West Randolph Street, Suite 4-600, Chicago, Illinois 60601. Fax copies will no longer be accepted.
The Office will INVOICE you for the initial certification fee of $100.00 or the annual renewal fee of $75.00. Any renewal
application of Certificate of Operation that has expired will be subject to an additional Late Fee of $50.00(PLEASE DO NOT
SEND MONEY WITH THIS APPLICATION). A copy of a final inspection report indicating the conveyance has PASSED
inspection must also be submitted with each application. The Elevator Safety Division will process the application(s) in the
order that they are received, and shall issue a certificate of operation for each conveyance upon payment of the invoice. This
certificate must be displayed in the conveyance and must be renewed on an annual basis based on an annual conveyance
inspection.
NOTE: Your conveyance MUST be registered with the State of Illinois prior to requesting a Certificate of Operation.
THIS SECTION FOR OFFICIAL USE ONLY
_____________________________________________ _________________________________________
Illinois Certificate of Operation Date Entered
1. Building Location
Name of Building:
County:
Building Address
City/State/Zip Code
Nature of Business:
Conveyance Registration No.:
2. Building Owner
Name of Building Owner:
Owner’s Address
City/State/Zip Code):
Phone No. of Owner:
Email Address:
3. Billing information (If different than Owner Information)
Name on Invoice:
Telephone Number:
Address (include City/State/Zip Code):
Email Address (an electronic copy of the invoice will be sent to this address and you will be able to pay online):
4. Signature (Contact Person for this conveyance – All mail will be sent to this person with the exception of
invoices)
I certify under penalty of perjury that the information on this application is true and complete to the best of my knowledge.
Signature _______________________________________________ Date: ___________________________________
Print Name (and Title) ______________________________________________________________________________
Name of Company _________________________________________________________________________________
Address __________________________________________________________________________________________
Contact Phone Number _______________________________ Contact Fax Number ___________________________
Contact Email: ____________________________________________________________________________________
Revised 08/23/2017 res
The Identity Protection Act, 5 ILCS 179/1 et seq., requires each local and State government agency to draft, approve, and implement an
Identity-Protection Policy that includes a statement of the purpose or purposes for which the agency is collecting and using an individual’s
Social Security Number (SSN). This statement of purpose is being provided to you because you have been asked by the OSFM to provide
your SSN or because you requested a copy of this statement. You are being asked for your SSN for one or more of the following reasons:
Internal verification and/or potential collection of fees, penalties or fines. We will only use your SSN for the purpose for which it was
collected. We will not: Sell, lease, loan, trade, or rent your SSN to a third party for any purpose; Publicly post or display your SSN; Print your
SSN on any card required for you to access our services; Require you to transmit your SSN over the Internet, unless the connection is secure
or your SSN is encrypted; or Print your SSN on any materials that are mailed to you, unless state or federal law requires that number to be
on documents mailed to you, or unless we are confirming the accuracy of your SSN.
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Illinois Office of the State Fire Marshal APPLICATION FOR CERTIFICATE OF OPERATION - ANNUAL

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Completed 9 December 2019

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