Minnesota Department of Labor and Industry Construction Codes and Licensing Division Elevator Inspections 443 Lafayette Road

North St. Paul, MN 55155-4341 Phone: (651) 284-5068 Fax: (651) 284-5749 www.doli.state.mn.us TTY: (651) 297-4198 Annual 5-Year

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Elevator Witness Load Test
PRINT IN INK or TYPE your responses.

Acceptance

Alteration

Complete all items at time of acceptance, alteration, or 5-year tests. Complete asterisk (*) items for annual inspection. Write “N/A” if not applicable. TYPE OF MACHINE MANUFACTURER OWNER’S DESIGNATION STATE IDENTIFICATION NO. Rated load (lbs.) OWNER NAME OWNER ADDRESS CITY STATE Rated speed ft/min. No. of openings

FREIGHT WHEELCHAIR SERIAL NO. No. of landings

PASSENGER SPECIAL APPLICATION?

Installation code year

Alteration code year

ELEVATOR LOCATION ELEVATOR ADDRESS ZIP CODE CITY STATE ZIP CODE

Car speed loaded: ft/min

*Car speed unloaded: ft/min

*Unloaded working *Relief valve Loaded working pressure at pump: psi pressure at pump: psi pressure: psi *Relief valve sealed? Yes No If leaking, why? Governor ropes: *Governor sealed: Yes No Cwt. Date sealed Yes No *Does car leak down? Yes No

Up Down Up Condition of hydraulic hose & fittings *Condition of packing:

Down Next replacement date of hydraulic hose: *Condition of piston:

Tripping speed-fpm: Car Car Car *Condition of oil: Cwt. Cwt.

Over-speed switch tripping speed fpm Car Cwt. Car *Condition of hoisting cables: Cwt.

Governor rope slide through jaws of governor?

Manila Iron Steel Car Governor sealed by whom:

Condition of governor rope prior to test: Condition of governor rope after test: Governor safety test tags applied? Rise Cwt. Car Rope data tag installed: Yes *Type of governor Car Cwt. No Yes Yes Yes No No No Cwt. Reshackle Date Ft. In. Bottom runby: Cwt.

Cwt. safety jaw railing marking: *Do all interlocks function properly? *Does car stop level at all floors? (1/2 in. above/below allowable) Ft. In.

*Do the safe edge and lights rays, or electronic door reopening device function properly? *Turns left on drum: *Door closing force measures (lbf.) *Length of safety rope pull out: Front Rear *Does slack cable switch work properly? *Car safety test tag applied? *Type of safety: Car Cwt. *Car safeties tested with Car safety jaw railing marking: Ft. In. Ft. Yes Yes Car pounds load at FPM No No In. *Does car safety switch work properly? *Cwt. safety test tag applied? Cwt. Car Yes Yes Cwt.

No No

*Condition of safeties prior to test:

*Condition of safeties after test: pounds load at FPM

*Cwt. safeties tests with

*Did car set level (3/8 inch per foot DBF allowable)? *Did Type C plank set level (1/2 inch allowable)?

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.

EL012 (6//07)

(over)

*Type of car buffers: Oil Spring

Were car & Cwt. run *Type of Cwt. buffers: onto buffers? Oil Spring Yes Yes Yes Yes No No No Yes No No

Oil plunger return within 90 seconds? Buffer test tag applied? Yes No Car Phase I fire service operational? Ascending care overspeed protection tested? *Do door restrictors work properly? Cwt. Yes Yes Yes No No No

Brake tested at 125% of rated load? Phase II fire service operational? *Does 2-way communication work properly?

*Emergency lighting and alarm bell operation tested: REMARKS AND REPAIRS MADE

Companies certifies that this test was performed to the requirements of ASME A17.1 or A18.1 COMPANY PERFORMING TEST MECHANIC PERFORMING TEST TEST WITNESSED BY INSPECTOR DATE DATE