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ELEVATOR REPORT OF INSPECTION
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Date Inspected
Next Inspection Due Date
Certificate posted?
Yes
No
Elevator #
Location (building name)
Street Address, City, Zip
Owner Name, Street Address, City, State, Zip or P.O. Box
Phone- local
Lessee/Management firm
Street Address, City, Zip, County
Maintenance Contract?
If yes, company name and branch
Type of Inspection
A- Annual
B- Installation
C- Construction
D- Complaint
E- Reinspection
F- Accident
G- Periodic
H- Alteration
Type of Unit
Pass
Frt
Esc.
DW
H.L.
other
If Other, specify
Elevator Status
active
dormant
temporarily decommissioned
destroyed
revoked
Type of machine
Tractio
Hydraulic
Drum
Other
If Other, specify
Speed
Capacity
# of openings on car
# of Floors
Door Width
Door Torque
Door Close Sp.
Type Door
Due Date 5 Yr. Safety Test
Violations
I hereby certify this is a true report of my inspection.
Clear Signature
Inspector ID#
Date
Clear Signature
Submit
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