Fillable Please submit a separate application for each elevator (North Dakota State Electrical Board)

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Please submit a separate application for each elevator (North Dakota State Electrical Board)

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• Please submit a separate application for each elevator or dumbwaiter.
Elevator and Dumbwaiter Horsepower Rating & Fee (select one)
☐ Up to 5 HP ($25.00) ☐ 5 HP through 15 HP ($40.00) ☐ Over 15 HP ($60.00)
Manufacturer
Model or Serial Number
Size
Number of Floors
Contact Person
Work Telephone Number
Cell Phone Number
Name of Site
Address
City
State
Location of Unit within Site
Estimated Completion Date
Name (First, Last)
Company
Title
Address
City
State
ZIP Code
Work Telephone Number
Cell Phone Number
Signed
Date
Submit completed application to:
North Dakota State Electrical Board Phone: 701-328-9522
PO Box 7335 Fax: 701-328-9524
Bismarck, ND 58507 Email address: electric@nd.gov
Website: www.ndseb.com
APPLICATION FOR INSPECTION OF MOTOR DRIVEN
PASSENGER OR FREIGHT ELEVATORS AND DUMBWAITERS
NORTH DAKOTA STATE ELECTRICAL BOARD
SFN 61922 (12-2020)
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Completed 21 April 2021

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