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Unit Type
Dumbwaiter
Passenger Elevator
Freight Elevator
Periodic
Acceptance
Inspection Type
Building and Unit Information
Building Name
Unit Identification:
Address
Chicago, IL
Manufacturer
Phone No.
Speed
fpm
Building Representative
Capacity
lbs
1. ELEVATOR-INSIDE OF CAR
OK
NG
NA
2.34
1.12
Car enclosure
2.36
1.14
Ventilation
2.37
1.15
2.38
1.16
2.39
1.17
NA
Emergency exit
NG
2.35
1.13
2.40
Inspection control
Maintenance records
Static control
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
2.1
2.2
2.3
2.4
Machine space
2.5
Housekeeping
2.6
Ventilation
2.7
Fire extinguisher
2.8
2.9
OK
2.10
Numbering of elevators,machines,disconnects
2.11
2.12
2.13
2.14
2.15
2.16
2.17
2.18
2.19
2.20
2.21
2.22
2.23
1.18
1.19
2. ELEVATOR-MACHINE ROOM
OK
NG
NA
OK
NG
NA
Hoistway construction
2.24
2.25
2.26
2.27
2.28
2.29
2.30
2.31
2.32
2.33
(H) Tanks
(H) Flexible hydraulic hose & fitting
assemblies
2.41
2.42
3. ELEVATOR-TOP OF CAR
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
3.10
3.11
3.12
3.13
3.14
Hoistway clearances
3.15
Multiple hoistways
3.16
3.17
3.18
3.19
3.20
Governor rope
3.21
3.22
3.23
(Continuation)
Unit ID:
3. ELEVATOR-TOP OF CAR (cont.)
5. ELEVATOR-PIT
OK
NG
NA
5.1
5.2
5.3
3.27
Traveling cables
Counterweight safeties
5.6
3.30
5.5
3.29
5.4
3.28
5.7
5.8
5.9
5.10
5.11
5.12
5.13
5.14
3.24
3.25
3.26
3.31
3.32
3.33
4.1
4.2
4.3
4. ELEVATOR-OUTSIDE HOISTWAY
Car platform guard
Hoistway doors
Vision panels
OK
NG
NA
4.4
4.5
4.6
4.7
Access to hoistway
Power closing of hoistway doors
Sequence operation
4.8
Hoistway enclosure
4.9
4.10
4.11
4.12
4.13
Item
No.
OK
NG
NA
OK
NG
NA
6. ELEVATOR-FIRE SERVICE
6.1
6.2
6.3
Phase I Operation
Phase II Operation
FAID (Fire Alarm Initiating Device) Operation
OK meets requirement
NG No Good (Insert number to identify comment on form)
NA not applicable
(T) Traction Elevators only
(H) Hydraulic elevators only
(*) - installed under A17.1b-1989 and later editions
Code
Reference
Comment
Inspection Status:
Date of Inspection:
Street Address
Code Edition:
FAIL
PASS
Permit Req'd
Inspector QEI #
Inspectors State License #
Inspectors Signature:
Revised 2-10-2011
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