Owner and/or Billing Contact Info:
Name:
Address:
City:
State/Zip:
Phone: / Object Location:
Site:
Address:
City
State/Zip:
County:
Location On Property: / Investigation ID: /
Regulated Object ID
Date Inspected: / Inspect Fee:None$90.00$120.00$150.00$200.00$250.00$300.00$400.00$500.00 / PTO Fee:
$50.00PlanN/A / Special:
Issue PTO / PTO on Hold
Type of inspection: AcceptanceRoutineReinspectionSpecialAudit
Regulated Object Information / Attributes
WI Registration Tag Number:
Family: Elevators
Type: ElevatorLift/VerticalLift/InclineLift/ChairDumbwaiterEscalatorMoving WalkLULAStage Lift
Last Investigation: Cycle: 1 yr.3 yr.
PTO Expiration: Next:
Serving Dwelling Unit: / Use: PassengerDumbwaiterFreight Class AFreight Class BFreight Class C1Freight Class C2Freight Class C3Limited Use Limited AccessPart VVertical Platform LiftEscalatorMoving WalkConstruction FreightConstruction PassengerStair Chair LiftInclined Platform Lift
Manufacture:
Number of Landings: Number of Car Entrances:
Type of Drive Unit: Direct HydraulicOil HydraulicTractionScrew DriveRack and PinionRoped HydraulicWinding DrumDrive ChainHandElectricRoller ChainWater HydraulicOther
Working PSI: Relief PSI:
Machine Roomless Traction:Basement Traction: / Rated Load (lbs):
Speed (fpm) Up: Down:
Number of Ropes: Size: None1/8"3/16"1/4"5/16"3/8"7/16"1/2"9/16"5/8"3/4"7/8"1"3mm7mm9mm13mm16mm19mm22mm25mm60mm
Number of Chains: Size:
Fire Service: Phase IPhase IINone
Valve Sealed: YesNoN/A
History:
Contract Date / Comm. 18 / IND. 4 / ASME / NEC / NFPA 13 – 13 R / NFPA 72 –72 E / Description of Work / Required Tests
5yr Safety/Gov. Test Date:
Annual Hydraulic Test Date:
Category 1 Test Date:
Category 5 Test Date:
Inspector Name:
e-mail :
Wisconsin Credential Number:
I certify this is a true and accurate report of my inspection.
Signature: / Employed by: / Onsite Contact:
Contact’s Phone:
Contact’s Email:
Phone: / Fax:
Remarks
Item No. / Code Section / Code violations listed below shall be corrected by COMPLIANCE DATE:*
*See the back of this report for important compliance information regarding this ORDER.
Department Order
This DEPARTMENT ORDER is issued as a result of an inspection conducted for the
Regulated Object referenced on the front of this report. You are hereby ordered to
have the listed violation(s) corrected to conform to the indicated provisions of the
Wisconsin Administrative code and/or statutes. These violations must be corrected
by the Compliance Date noted, and upon correction of the violations, the inspector
who signed this report must be notified in writing. If you fail to comply, this order is
enforceable in circuit court pursuant to s.101.02 (13), Stats., with forfeitures ranging
from $10 to $100 per day for each violation. In addition, the Department may attach
a notice of violation to the deed for the property on which the violations occur. If you
have questions regarding this matter, please feel free to contact the inspector at the
number provided on the front of this report.
Accident Reporting:
Whenever an elevator or other installation covered by this chapter causes injury to
any person, the owner or person in control of the elevator shall notify the department
within 48 hours of the accident. The report shall include the date and time of the
accident, the location of the elevator or device involved in the accident and
description of the accident.
Note: The department may be contacted at phone: (608) 266-2112 during
normal business hours. The State Division of Emergency Management can be
contacted at (800) 943-0003 during non-business hours.